Failure to Notify Physician of Significant Weight Changes for Resident on Diuretic
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for monitoring and reporting significant weight changes for a resident receiving a high‑risk medication. The resident had moderate cognitive impairment with a BIMS score of 8 and medical diagnoses including renal insufficiency, hypertension, diabetes mellitus, hyperlipidemia, and stroke. The resident’s MDS indicated use of a diuretic, and the care plan identified a problem of edema/fluid volume overload with goals for stable fluid volume and interventions that included informing the physician of increased edema, obtaining labs as ordered, administering medications as ordered while monitoring for side effects and effectiveness, and promptly notifying the physician of specified clinical changes. A physician order dated 12/8/25 directed staff to obtain daily weights prior to eating and drinking, notify the physician of weight changes of 3 pounds in 1 day or 5 pounds in 7 days, and send the information to the clinic for review. Review of the March 2026 MAR showed multiple significant daily weight fluctuations for this resident, including a decrease from 172.3 pounds to 165.7 pounds (6.6 pounds) in one day, an increase from 165.7 pounds to 170.7 pounds (5 pounds) in one day, and an increase from 169.6 pounds to 173.9 pounds (4.3 pounds) in one day. Review of the EHR revealed no documentation that the physician was notified of these weight changes as required by the 12/8/25 order. In an interview, the DON confirmed that the physician had not been notified of the March weight changes in accordance with the order and acknowledged that staff did not follow the physician’s orders, despite the facility’s policy on Provision of Physician Ordered Services, which states its purpose is to provide a reliable process for proper and consistent provision of physician‑ordered services according to professional standards of quality.
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