Failure to Obtain Ordered and Admission Weights and Notify Physician of Critical Blood Glucose
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights and to notify the physician as ordered, as well as delays in obtaining admission weights. For one resident with acute respiratory failure with hypoxia, COPD with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema, a physician’s order dated 12/2/25 required a daily weight once a day, and the care plan reflected this order. However, the MAR for December and January showed multiple days on which the daily weight was not obtained or documented. Facility staff, including a QMA and the DON, stated that daily weights should be completed every day, typically in the morning before breakfast. Another resident with severe protein-calorie malnutrition, encephalopathy, pneumonia, rhabdomyolysis, atherosclerotic heart disease, ischemic cardiomyopathy, repeated falls, hypovolemic shock, and gastrostomy status had physician’s orders on consecutive days to obtain an admission weight, but the admission weight of 106.5 pounds was not obtained and documented until six days after admission, contrary to staff statements that admission weights should be completed on the day of admission or within 24 hours. A third resident with diabetes mellitus and a right fibula fracture had a care plan indicating use of hypoglycemia medication and risk for adverse effects, with interventions including administering medication as ordered. A physician’s order directed staff to administer Humalog insulin per sliding scale and to call the physician for blood sugars less than 60 or greater than 400. The clinical record showed a blood sugar of 435, but the NP was not notified until several days later, as documented in an IDT note and confirmed by the Clinical Support Nurse. A fourth resident with a history of UTI and cerebrovascular accident had an admission weight of 165 pounds obtained and documented several days after admission, despite facility policy and staff statements that admission observation and data collection, including weight, should be initiated within 12 hours and completed within 24 hours. Facility policies on admission nursing observation and weight monitoring required timely completion of admission assessments and daily review of missing admission and ordered weights, but the records for these residents showed that these processes were not followed as required.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.