Failure to Administer Diuretic as Ordered for Weight Gain
Penalty
Summary
The facility failed to follow a physician's order for medication administration, resulting in a resident not receiving their prescribed diuretic (Lasix) as needed when their weight increased by 3 pounds from baseline. The resident, who had diagnoses including congestive heart failure, hypertension, renal and respiratory failure, and required supervision or partial assistance with activities of daily living, was to receive Lasix 20 mg orally daily as needed for weight gain. Clinical records and the Medication Administration Record (MAR) showed that on several occasions when the resident's weight met or exceeded the threshold for administration, the medication was not given as ordered. The care plan and physician orders specifically directed staff to monitor daily weights and administer Lasix accordingly. Despite these instructions, documentation revealed that the resident's weight increased above the baseline on multiple dates without the corresponding administration of the diuretic. Staff interviews confirmed that nurses were expected to follow physician orders as written, but the review of the clinical record indicated this did not occur, resulting in the resident not receiving the medication as prescribed.