Failure to Notify Physician of Significant Weight Gain in Resident With Heart Failure
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for change in condition notification related to a resident with heart failure. The resident, an older female with diagnoses including coronary artery disease, heart failure, renal insufficiency, and pneumonia, had a care plan that included monitoring for changes in condition and weighing as ordered for altered cardiovascular status. A physician order directed staff to obtain a daily weight before breakfast and to notify the physician if the resident gained 3 lbs overnight or 5 lbs or more in one week. Electronic medical record review showed the resident’s weight increased from 92.6 lbs on 1/19/2026 to 96.6 lbs on 1/20/2026, a 4 lb overnight gain that met the threshold for required physician notification. Progress notes from 12/29/2025 to 1/29/2026 did not contain any documentation that the physician was notified of this significant weight gain. A nutrition note dated 1/20/2026 referenced a current weight of 92.6 lbs from the prior day, and a skilled nursing note on 1/20/2026 documented vital signs within normal limits with no concerns noted, without addressing the weight change. During interview, the DON acknowledged that staff did not notify the physician of the 4 lb weight gain and stated that the congestive heart failure was the reason for the 3 lb weight gain notification parameter. The facility’s Change of Condition Policy required licensed nurses to evaluate significant changes in status and notify the physician and responsible party, and to document the notification and any new orders, which was not done in this case.
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