Failure to Follow Physician Orders for Nutritional Monitoring and Notification
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for monitoring and responding to a resident’s nutritional risk. Resident 8, who had diagnoses including diabetes, Alzheimer’s disease, and epilepsy, had a physician order dated 1/13/26 stating the resident was at risk for malnutrition related to comorbidities. The order directed nursing to monitor weight and intakes as ordered, monitor dental status for adequate chewing ability, follow up with the dietitian as recommended, monitor medications for adverse effects such as nausea, vomiting, diarrhea, and decreased appetite, monitor for negative outcomes such as decreased oral intake or weight loss, and notify the physician every shift. Record review showed that Resident 8’s weight decreased from 175 lbs on 2/9/26 to 168.8 lbs on 3/4/26, a 3.54% loss in 23 days, with no documentation that the physician was notified of this weight loss. Progress notes for March 2026 contained no evidence of physician notification regarding the weight loss, and the physician communication book for 3/4/26 through 3/10/26 also lacked any entry about this issue. The DON stated that staff are expected to fax or call the provider about resident changes and document physician notification in a progress note, but confirmed there was no such documentation for this resident. A QMA reported that the resident ate in the restorative dining room so staff could assist and monitor intakes, and that changes in eating would be reported to a nurse. Review of intake records between 2/9/26 and 3/4/26 showed multiple meals at 50% or less intake, including several meals at 1–25% or zero, with no documentation that alternatives or supplements were offered. An LPN explained that staff receive alerts when weight changes require dietitian notification and that staff become concerned at specified weight-loss thresholds, but there was no documentation that the physician was notified as ordered. The facility’s Provider Notification Guidelines policy required documentation of attempts to notify the provider and their response in the electronic health record but did not address following specific physician orders.
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