Failure to Notify Physician of Significant Weight Gain for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to notify the provider of a specified weight gain for a resident with chronic congestive heart failure (CHF). Record review showed that the resident, who was receiving a daily diuretic for CHF per a Quarterly MDS dated 1/12/2026, had a physician’s order dated 1/14/2026 to be weighed daily and for the physician to be called for a gain of 3 pounds in one day or 5 pounds in one week. The MAR documented that the resident’s weight was 197 pounds on 2/8/2026 and 200.1 pounds on 2/9/2026, reflecting a 3.1-pound gain in one day. Despite this documented weight increase meeting the threshold in the physician’s order, the MAR indicated that the physician was not notified of the 3.1-pound gain. In an interview, the DON confirmed that the physician should have been notified of the weight gain and stated that the facility did not have a policy regarding following physician orders, indicating they followed standards of practice instead.
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