Failure to Follow Weight Monitoring and Nutritional Supplement Orders
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident when staff did not follow physician orders for weight monitoring and nutritional supplementation. The resident had an order dated 10/16/25 to be weighed weekly for four weeks and then monthly, and a subsequent order dated 10/27/25 for a house nutritional supplement (house shake) 4 oz twice daily for poor intake. Record review showed that for October 2025 the resident’s weight was documented only once, on 10/16/25, instead of weekly as ordered, and the house shake supplement was documented as given only twice on 10/31/25, rather than twice daily as ordered. During an interview, the resident’s sister reported that the resident was experiencing tooth pain and had lost weight because eating caused pain. In a later interview, the Regional Clinical Nurse confirmed that the resident was not weighed per the physician’s order and that there was no documentation that the ordered house supplement was provided as directed, acknowledging that physician orders should be followed and that supplement administration should be documented in the record. These findings were based on record review and interviews and involved one of three residents reviewed for nutrition and maintenance of acceptable parameters of nutritional status.
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