Failure to Follow Physician Orders for Weekly Weights in Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders for weight monitoring were followed for multiple residents receiving dialysis. Facility policies on physician orders and dialysis required that orders be transcribed and followed as prescribed, with all obtained weights documented in the electronic medical record (EMR), and that there be ongoing communication and coordination with dialysis staff. Despite these policies, four of five residents identified as receiving dialysis services had missing or inconsistent weight documentation in the EMR, even though they had active orders for weekly weights. One resident with congestive heart failure, a history of thrombotic pulmonary emboli, and iron deficiency anemia had multiple overlapping weekly weight orders with specified start and stop dates, but no weights recorded in the EMR for October 2025, January 2026, or February 2026, and only two weights documented in November and December 2025. The most recent dialysis communication sheet for this resident showed a post-dialysis weight in mid-December 2025, but this information was not reflected as ongoing weight entries in the EMR. Another cognitively intact resident with ESRD, a history of TIA, and a prior MI had an active order for weekly Sunday weights, yet had no recorded weights in November 2025 or January 2026, and only sporadic weights documented in December 2025, late February 2026, and early March 2026. A third cognitively intact resident with ESRD, a history of TIA, unspecified heart failure, and coronary artery disease had weekly weight orders, including an active order for Monday day-shift weights, but had no recorded weights in December 2025 or January 2026 and only two weights documented in February and March 2026. A fourth cognitively intact resident with ESRD, essential hypertension, iron deficiency anemia, and insomnia had an active weekly weight order, but only three weights were documented over a roughly six-week period. Staff interviews with an LPN, a CMT, and facility leadership confirmed that residents on dialysis typically have weekly weight orders, that any nursing staff member can obtain and record weights in the EMR, and that dialysis communication forms are supposed to be collected and transcribed. The DON, ADON, and an LPN reported that the previous DON had been receiving dialysis communication forms but had failed to upload or transcribe most of the post-dialysis weights into the EMR, contributing to the incomplete weight records identified by surveyors.
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