Failure to Complete Physician-Ordered Daily Weights and Notify Physician
Penalty
Summary
The facility failed to provide physician-ordered daily weights for a resident with heart failure, hypertension, and coronary artery disease. The resident's Minimum Data Set (MDS) indicated no cognitive impairment, and the physician's order specified daily weights if there was a weight gain of more than 3 pounds in one day or more than 5 pounds in one week, with weekly faxing of weights. However, daily weight records showed multiple missed days over a three-month period, and there was no documentation that the physician had been notified about the missed weights or that the monitoring was occurring as ordered. Facility policy required supervision of medical care, including monitoring changes in residents' medical status and overseeing relevant care plans. Interviews confirmed that daily weights should have been completed and the physician notified if they were not.