Failure to Implement Physician Orders for Physical Restraints and Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders and care plans for two residents, resulting in deficiencies related to physical restraints and weight monitoring. For one resident with moderate cognitive impairment and a history of unsteady gait and dizziness, the care plan and physician orders specified the use of a right-sided 1/4 size bed rail (mobility bar) to assist with bed mobility and transfers. Observations on multiple occasions revealed that the bed rail was not installed, and both staff and the resident confirmed that it had never been put in place since admission, despite the documented order and consent. Another resident, also moderately cognitively impaired and diagnosed with congestive heart failure, had a physician order for daily weights with instructions to notify the physician if weight gain exceeded specified thresholds. Record reviews showed multiple instances of significant weight gain without documentation of physician notification, as well as repeated failures to obtain daily weights on numerous days across several months. Staff interviews confirmed the absence of required documentation and acknowledged that the physician had not been notified as ordered.