F0580

J

Failure to Notify Physician of Significant Weight Gain and Fluid Overload Signs

Wurtland, Kentucky Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and notify a physician of a resident’s significant weight gain and associated symptoms, as required by facility policy and the resident’s care plan. The facility’s Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, primary hypertension, atrial fibrillation, and hypertension, and had a care plan intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, documenting abnormal findings and notifying the physician. The physician’s orders included weekly weights.

From admission, the resident’s weight increased from 252.8 pounds to 259 pounds within four days, a gain of 6.2 pounds, and then to 267 pounds within nine days, a total gain of 14.2 pounds from admission. These weights were entered by the DON and an LPN, respectively. There was no documentation that the provider was notified of either the 6.2‑pound gain in four days or the 14.2‑pound gain in nine days, despite the facility policy requiring notification for a three‑pound gain in one week. Nursing documentation also showed that the resident had shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation that the physician was notified of these abnormal findings, contrary to the resident’s care plan interventions.

The resident’s weight continued to increase, reaching 270 pounds 13 days after admission, a total gain of 17.2 pounds. On that date, an LPN documented +3 to +4 pitting edema in all four extremities and shortness of breath, and notified the APRN, obtaining orders for a chest x‑ray, labs, and intramuscular furosemide. The resident was sent to the hospital for evaluation at the request of a family member. Interviews with the family member indicated he observed increasing swelling of the resident’s legs, feet, and scrotum throughout the stay and reported these concerns daily to staff, who told him the edema was not a problem. Interviews with the APRN, Medical Director, DON, and Administrator confirmed that staff were expected to notify a provider of significant weight changes and changes in condition, and that there was no evidence staff had identified the resident’s weight gain as a significant change in condition or notified the APRN or physician of the repeated weight gains prior to the date when the APRN was finally contacted.