Failure to Monitor Daily Weights for CHF Resident
Penalty
Summary
Nursing personnel failed to follow physician orders and facility policy regarding daily weight monitoring for a resident diagnosed with congestive heart failure (CHF). The resident had clear orders from both the nurse practitioner and physician for daily weights to monitor CHF, with instructions to notify the provider if there was a significant weight change. However, the medical record and weight logs showed that weights were not obtained daily as ordered, with large gaps between recorded weights. The Medication Administration Record (MAR) indicated weights were sometimes completed, refused, held, or marked as 'other/see progress notes,' but the actual weight record only showed sporadic entries. Over a three-month period, the resident experienced a significant weight loss of 43.4 lbs, yet daily monitoring was not consistently performed or documented. Interviews with facility staff, including the Director of Nursing (DON) and Physical Therapy Director (PTD), revealed confusion and lack of clarity regarding responsibility for obtaining weights. The DON acknowledged awareness of the daily weight order and agreed that refusals and physician notifications should be documented, but could not provide evidence that refusals or physician notifications were consistently recorded. The PTD denied that therapy staff were responsible for weighing residents, despite a progress note suggesting otherwise. The facility's own policies required prompt notification of significant changes in condition and documentation of refusals, but these were not followed in this case.