Failure to Complete and Document Ordered Daily Weights for Heart Failure Management
Penalty
Summary
A resident with a diagnosis of heart failure was admitted to the facility and later had a physician’s order dated 10/24/24 for a daily weight at 8:00 AM, with instructions to notify the MD for specified weight gains related to heart failure management. Review of the resident’s electronic MAR for June 1–24, 2025, showed that daily weights were not obtained or documented on 7 of 24 ordered days, and there was no documented reason for the missed weights. During interview, an RN stated it was the nurse’s responsibility to weigh the resident and acknowledged that the resident sometimes refused, but the clinical record contained no evidence that the resident had refused the ordered weights. The deficiency centers on the facility’s failure to provide and document ordered daily weights and any refusals, as required by the physician’s order for heart failure monitoring.
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