Failure to Notify Physician of Repeated Refusal of Ordered Daily Weights
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the physician when a resident repeatedly refused ordered daily weights or when weights were not completed. The resident had diagnoses of heart failure, diabetes mellitus, and hypertension, and an MDS assessment documented a BIMS score of 15, indicating no cognitive impairment. A physician-signed order dated 1/29/26 required daily weights, with PRN Bumetanide and instructions to notify the physician for specified weight gains. Review of the January, February, and March 2026 Medication Administration Records showed multiple days where daily weights were either refused or marked as not applicable, including numerous refusals across all three months. Despite these repeated refusals and missed weights, review of the clinical record showed no documentation that the physician had been notified about the resident’s refusal of daily weights or the failure to complete them. The facility also lacked a policy addressing physician notification in such circumstances. During an interview, the ADON confirmed there was no documentation of physician notification regarding the resident’s refusal of daily weights or incomplete weights, although the ADON stated an expectation that staff notify the physician when orders are not being completed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.