F0658

E

Failure to Follow Physician Orders and Reweigh Policy for Significant Weight Changes

Newport, Rhode Island Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to meet professional standards of quality by not following physician orders and its own weight assessment policy for multiple residents. For one resident with hemiplegia, hemiparesis, and adult failure to thrive who was readmitted in October 2025, physician orders required monthly weights beginning in August 2025 and weekly weights for four weeks starting in January 2026. The clinical record showed weights documented in September, November, January, and February, but there was no evidence that weights were obtained in October and December as ordered. During interviews, the Dietitian and the Director of Nursing Services acknowledged that the ordered weights for this resident in October and December 2025 could not be verified.

The facility also failed to follow its policy titled “Weight Assessment and Interventions,” which requires that any weight change of 5 lbs in a month or 3 lbs in a week be rechecked within 72 hours for confirmation and verified by nursing. For the first resident, the record showed a 13.4 lb loss between early November and early January, a 3.8 lb loss between early and mid-January, and a 4.2 lb loss between late January and mid-February, with no documentation that any of these weights were rechecked. For a second resident admitted in November 2025 with type 2 diabetes mellitus and ordered to have weekly weights for four weeks, the record showed multiple significant weight gains between early November and early February, including gains of 7.8 lbs, 10.4 lbs, 7.8 lbs, and 6 lbs between successive weigh dates, without evidence of required reweights. The Dietitian confirmed that reweights were not obtained per policy for these residents, and the Director of Nursing Services was unable to provide documentation of the required reweights.