F0684

D

Failure to Implement and Document Ordered Weekly Weights for Residents with CHF and Edema

Lebanon, Indiana Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for weekly weights for two residents with CHF, edema, and lymphedema. For one resident, multiple observations over several days showed the resident asleep in a recliner with legs elevated, wearing pants that had been cut from the hem to the calf and appeared wet, with bilateral lower leg edema noted each time. The resident’s care plans, addressing CHF, edema, diuretic use, and nutritional risk, directed staff to obtain and document weights as ordered. A physician’s order dated 12/19/25 specified weekly weights on Tuesday mornings. However, review of the MAR showed that staff documented weekly temperatures instead of weights, and the vitals section of the EHR contained no documentation of the ordered weekly weights.

Interviews revealed that the QMA/Scheduler responsible for obtaining weights acknowledged that temperatures were documented instead of weights and that she was responsible for ensuring weights were completed and re-weights obtained for significant changes. An LPN confirmed that the physician’s order was for weekly weights but that temperatures were entered and documented, indicating the order had been entered incorrectly into the EHR. The Clinical Support Nurse explained that the order had been placed in the EHR with a task incorrectly set to “temperature” rather than “weight,” and that the IDT reviewed only the compiled weight report, not the underlying orders, when monitoring residents. The Executive Director stated that a nurse should have caught the entry error when completing the task, and the NP indicated that weights were difficult to monitor because they were not always documented in the same EHR location and that she relied on nurses to notify her of changes.

For the second resident, observations documented the presence of a midline IV in the right upper arm and bilateral lower extremity edema, with the resident reporting weight gain from swelling and uncertainty about how often he was weighed. An empty IV bag labeled Furosemide 80 mg IV was observed, and later the midline had been removed while edema persisted. The resident’s diagnoses included CHF, edema, and lymphedema, and a care plan directed that his weight be obtained and documented per order. A physician visit note dated 1/28/26 included a plan to monitor weekly weights, but no weekly weight documentation or corresponding physician order was found in the EHR. A change in condition note on 2/20/26 documented increased edema and shortness of breath and new orders for IV Furosemide and fluid restriction, but did not include weight monitoring. A progress note on 2/25/26 stated that the DON contacted the MD, confirmed IV Lasix 80 mg, and indicated the resident was placed on daily weights, yet no daily weight documentation or physician order for daily weights was found in the EHR. In a later text message, the MD clarified the resident was supposed to be on weekly weights, and the DON acknowledged she had not placed an order for weekly weights in the EHR, contrary to the facility’s policy requiring physician orders to be followed and reviewed.