Failure to Obtain and Document Daily Weights for Residents with Fluid Management Needs
Penalty
Summary
The facility failed to follow physician orders to obtain and document daily weights for two residents with diagnoses including congestive heart failure and fluid overload. For one resident, there were 33 instances over several months where daily weights were not recorded, despite clear physician orders and care plan interventions specifying the need for daily monitoring. The resident's responsible party reported that the facility provided various excuses for not obtaining weights, such as malfunctioning equipment or inability to locate the scale, and that the facility did not implement the physician's orders in a timely manner. There was no documentation indicating that the resident refused to be weighed on the missed days. Staff interviews revealed that the CNA/Weight Tech was responsible for obtaining weights Monday through Friday, while floor CNAs were expected to obtain weights on weekends. However, the process for ensuring weights were obtained on weekends was not effectively managed, and nurses were identified as ultimately responsible for ensuring compliance with orders. The Assistant Director of Nursing (ADON) generated weekly weight reports but did not verify daily compliance by reviewing each resident's chart, resulting in unawareness of the missed weights. The Director of Nursing (DON) and ADON both confirmed that staff should have identified and addressed the missed weights, and that the resident could have been weighed even if in a chair using a Hoyer lift. A second resident with orders for daily weights also had undocumented weights on two consecutive weekends. The ADON confirmed that daily weights were ordered and acknowledged that staff did not identify the missed documentation. Both residents had medical conditions requiring close monitoring of fluid status, and the failure to obtain and document daily weights as ordered was confirmed through record review and staff interviews.