Failure to Notify Provider of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the provider of a significant weight gain in a resident with a history of congestive heart failure (CHF) who was prescribed diuretic medications. The resident was admitted with multiple diagnoses, including CHF, atrial fibrillation, hypertension, and peripheral vascular disease, and had physician orders for daily weights and diuretic therapy. Over a 19-day period, the resident experienced a weight gain of 26.8 pounds, increasing from 220.2 lbs to 247 lbs. Despite this significant change, there was no documentation that the physician or nurse practitioner was notified of the weight gain, as required for residents with CHF. Interviews with facility staff revealed that the nurse responsible for entering the resident's weight into the electronic medical record noticed an alert indicating a significant weight gain but did not compare the current and previous weights to confirm the extent of the change. As a result, neither the medical provider nor the registered dietitian was informed. Both the DON and the NP confirmed that their expectation was for the provider to be notified of such changes, especially given the resident's CHF diagnosis and the potential need for treatment adjustments.