Failure to Complete Physician-Ordered Admission Weights for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete physician-ordered daily admission weights for two residents, contrary to its own Weights policy requiring residents to be weighed on admission and at least monthly, or as ordered by the physician or care plan. The policy also allows for more frequent weights, such as weekly or bi-weekly, for residents at nutritional risk. One resident was admitted with multiple serious diagnoses, including lung cancer, brain cancer, chronic kidney disease, failure to thrive, muscle wasting and atrophy, and severe protein-calorie malnutrition. The Medication Administration Record shows a physician order beginning on 12/4/25 for height and weight upon admission and then daily for seven days, but only a single weight was documented on 12/4/25 with no additional weights recorded for the remainder of the month. Another resident had diagnoses including tracheostomy status, gastrostomy status, critical illness myopathy, a stage IV sacral pressure ulcer, and type 2 diabetes, and was receiving tube feeding with Osmolyte 1.5 at a specified rate and duration each day. The care plan directed staff to follow physician orders for current feeding orders and to obtain and monitor labs and diagnostics as ordered. The Physician Order Summary documented an order starting on 11/20/25 for height and weight upon admission and then daily for seven days. However, the Weights and Vitals summary shows this resident was weighed only on 11/21/25 and then not again until 12/31/25, and a nutrition progress note dated 12/29/25 recorded the last weight as 11/21/25. The Assistant DON confirmed that both residents did not have their ordered daily weights completed after admission.
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