Failure to Follow Physician Orders for Monthly Weights and Monitor Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident by not following physician orders for monthly weights. The resident, who had multiple sclerosis and was admitted with this diagnosis, had a quarterly MDS dated 12/08/25 that lacked a documented weight, despite instructions to base the weight on the most recent measure in the last 30 days. Physician orders included a regular texture, thin liquid diet, an order dated 02/04/25 to weigh the resident every month for routine monitoring, and an order dated 08/26/25 for Prostat nutritional supplement twice daily for wound healing. The resident’s care plan, dated 08/26/25, identified potential nutrition risk due to inadequate oral intake, non-significant weight loss, and increased nutrition needs related to wound care, with interventions that included weighing per physician orders. Review of the electronic health record weight tracking from 03/01/25 through 12/22/25 showed documented weights on 03/25/25 and 04/01/25 of 125.4 lbs and on 07/01/25 of 120.8 lbs, with no documented weights after 07/01/25. A nutritional evaluation dated 10/25/25 documented a 3% weight loss (4.6 lbs) compared to the 04/01/25 weight. During an interview on 12/22/25, the DON confirmed that the last documented weight was in July 2025, acknowledged that the resident should have been weighed monthly per physician orders, and stated that if the resident refused weights, this should have been documented in the EHR. The DON stated the resident’s weights were not being consistently monitored and should have been.
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