F0580

D

Failure to Notify Physician of Significant Weight Changes

Olney, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a physician of significant weight changes for a resident as required by physician orders and the care plan. The resident was admitted with diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a moderate cognitive deficit per the MDS. The care plan identified a problem of risk for impaired nutrition and hydration, with an intervention to monitor weight and notify the provider of significant weight changes. Physician orders directed staff to obtain daily weights before breakfast and to notify the physician for weight gain greater than 3 pounds in 1 day or 5 pounds in 1 week, and also included an order for PRN bumetanide to be given for specified weight gains.

The resident’s January weight records showed multiple instances where the notification parameters were met: a 3‑pound gain in one day on three separate dates and a 5‑pound gain in one week on another date. An LPN stated she noted a 3‑pound weight gain on one of those days and administered the PRN bumetanide but did not remember notifying the physician. The Regional Clinical Director reviewed the resident’s weights and progress notes and was unable to find documentation that the physician had been notified of the weight changes as ordered. The Nurse Practitioner who routinely followed the resident stated she had not been notified of any weight gains during that month and indicated that, if notified, she would have directed staff to administer the PRN bumetanide as ordered. The facility’s policy on obtaining and following physician orders states that if orders are not followed for any reason, the physician and DON will be promptly notified, which did not occur in this case.