Failure to Monitor Weekly Weights and Intake/Output for Resident with G-Tube and Catheter
Penalty
Summary
The facility failed to obtain weekly weights as ordered for one resident who had significant medical needs, including a gastrostomy tube (G-tube) and an indwelling catheter. The resident was admitted with diagnoses such as traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, and was dependent on staff for most activities of daily living. Physician's orders specified weekly weights for four weeks, but documentation showed that the weight for the third week was not obtained or recorded. Staff interviews confirmed that the weekly weight was missed, and facility policy required monitoring weights to detect undesirable or unintended weight loss or gain. Additionally, the facility did not ensure that staff monitored and documented the resident's intake and output (I/O) in accordance with professional standards and facility policy. Despite the resident having a G-tube and an indwelling catheter, there was no documented evidence of I/O monitoring from admission through the resident's most recent hospitalization. Staff interviews revealed that I/O monitoring was not included in the admission orders, and as a result, staff did not perform or document I/O in the Medication Administration Record. Facility policy required I/O monitoring for at least one month for residents with a G-tube and/or indwelling catheter, but this was not done for the resident in question. Interviews with nursing staff and facility leadership confirmed that the omission of I/O monitoring was due to a failure to include it in the admission orders and a lack of subsequent identification of this omission by clinical staff. The Director of Nursing stated that I/O monitoring should have been initiated upon admission and continued for the first four weeks, especially given the resident's history of pulling out the G-tube. Facility policies reviewed indicated that I/O monitoring is required for residents with urinary catheters and should be documented and evaluated weekly, but these procedures were not followed in this case.