Failure to Obtain and Document Daily Weights for Dialysis Resident
Penalty
Summary
A resident with chronic kidney disease, stage 3, type 2 diabetes mellitus with diabetic neuropathy, and polyneuropathy was admitted with a physician order for daily weights to monitor their condition related to dialysis. The facility failed to document that daily weights were obtained as ordered by the physician. The only weights available were those provided by the dialysis provider on dialysis days and a weight summary given to the surveyor. The Director of Nursing confirmed that nursing staff are responsible for weighing residents and are expected to follow physician orders, but acknowledged that no other daily weights were recorded for this resident. The facility's policy requires physician orders to be followed as written, and questions about orders to be clarified with the physician.