F0684

D

Failure to Transcribe Specialist Follow-Up Order and Notify Physician of Poor Intake and Weight Loss

Stockton, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered and needed care and treatment to two residents by not following hospital discharge instructions for a cardiology follow-up and by not notifying the physician of poor oral intake and weight loss. For the first resident, the admission record dated 3/6/26 showed diagnoses including respiratory failure, heart failure, and hypertension, and an MDS dated 2/19/26 documented a BIMS score of 12/15, indicating moderate cognitive impairment. The resident’s care plan report dated 12/2/25 identified altered cardiovascular status and hypertension, with an intervention to notify the MD of significant abnormalities. The acute hospital discharge summary dated 11/18/25 contained an order to follow up with a cardiologist in two weeks, but this order was not transcribed into the resident’s electronic order summary report.

The first resident reported during interview that she had scheduled cardiology appointments on 1/7/26 and 1/21/26, that the Social Services Director (SSD) had been informed, and that both appointments were missed. She produced two letters from the cardiologist documenting the missed appointments. The resident stated she later called the cardiologist’s office on 2/23/26 to make an appointment and learned an appointment had already been scheduled for 2/25/26, which she had not been informed about by staff. Licensed nursing staff interviewed stated they were not aware of the cardiology appointments, and review of the order summary report confirmed there was no cardiologist referral order documented. The SSD acknowledged being aware of the 1/7/26 and 1/21/26 appointments, stated that the appointments were missed due to lack of communication and poor coordination between departments, and admitted he did not upload the appointment information into the resident’s electronic file, resulting in the referral order not being followed through or carried out.

For the second resident, the admission record dated 3/10/26 showed diagnoses including stage 3 kidney disease, diabetes, and vascular dementia, with an MDS BIMS score of 11/15 indicating moderate cognitive impairment. A complainant reported that this resident had not been feeling well for several days and had not been eating for almost seven days before transfer to an acute hospital. The facility’s documentation survey report for February showed multiple consecutive meals from 2/13/26 through 2/17/26 where the resident either refused meals or consumed 0–25% of meals, including repeated entries of “RR” (resident refused) and “0” for intake. Weight and vitals documentation showed a decrease from 163.8 lbs on 2/8/26 to 155.8 lbs on 2/16/26. Physician progress notes dated 1/27/26 and 2/14/26 directed staff to monitor weight and intake/output and to notify the MD/provider if there was abnormal weight loss or poor PO intake.

Certified nursing staff reported that when residents refused meals they informed the charge nurse and offered snacks or alternatives, and nursing staff stated that for low meal intake they would complete a change of condition form and notify the primary care physician (PCP) and registered dietitian (RD). However, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that, despite the documented poor intake and weight loss, the PCP and RD were not notified during the period of low intake and weight decline. The ADON later verified that the PCP and RD were not notified until 3/4/26. Facility policies on Weight Monitoring and Nutritional Management required that the physician be informed of significant changes in weight, intake, or nutritional status, but this notification did not occur during the days when the resident had repeated meal refusals and low intake and experienced documented weight loss.