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Based on document review and interview, nursing services failed to obtain weights at least three times per week for 3 of 10 medical records reviewed (P1, P2, and P3); provide timely physician notification for weight loss for 3 of 10 medical records reviewed (P1, P2, P3, and P4); failed to notify physician of continuous patient intake refusal and nursing services failed to administer medication as ordered for 1 of 10 medical records reviewed (P5).

Findings include:

1. Review of policy/procedure titled, "Weights," Policy No.: CC.08, last revised 09/2024; indicated under policy: 2. Weights will be obtained at least three times a week. Indicated under procedure: 3. Nursing will notify the physician when weight loss exceeds 5 pounds in one week.

2. Review of P5 medical record indicated the following:
a. Medical record lacked documentation of provider notification of P5 consecutive meal refusals.

b. Review of P5's Dietary Tracking indicated the following:
05/28/25: P5 refused breakfast, 50% of their breakfast fluids, a.m. snack, a.m. snack fluids, lunch, lunch fluids, dinner, 50% of their dinner fluids, p.m. snack, and HS (night time) snack.
05/29/25: P5 refused breakfast, breakfast fluids, 25% of their a.m. snack, lunch, lunch fluids, p.m. snack, dinner, and HS snack.
05/30/31: P5 refused breakfast, 75% of their breakfast fluids, 25% of their a.m. snack, lunch, p.m. snack, dinner, and HS snack.
05/31/25: P5 refused breakfast, breakfast fluids, 25% of their a.m. snack, lunch, 25% of lunch fluids, p.m. snack, dinner, and 25% of their dinner fluids.
06/01/25: P5 refused breakfast, breakfast fluids, a.m. snack, lunch, lunch fluids, p.m. snack, p.m. snack fluids, dinner, and HS snack.
06/02/25: P5 refused breakfast, breakfast fluids, a.m. snack, lunch, 75% of their lunch fluids, p.m. snack, dinner, and HS snack.
06/03/25: P5 refused breakfast, 75% of their breakfast fluids, a.m. snack, a.m. snack fluids, lunch, lunch fluids, p.m. snack, dinner, 75% of their dinner fluids, and HS snack.
06/04/25: P5 refused breakfast, 75% of their a.m. snack, 75% of their a.m. snack fluids, lunch, p.m. snack, 25% of their p.m. snack fluids, dinner, and HS snack.
06/05/25: P5 refused breakfast, 75% of their a.m. snack, 75% of their a.m. snack fluids, lunch, lunch fluids, p.m. snack, dinner, and HS snack.
06/06/25: P5 refused breakfast, breakfast fluids, a.m. snack, a.m. snack fluids, lunch, p.m. snack, p.m. snack fluids, dinner fluids, dinner, and HS snack.
06/07/25: P5 refused breakfast, a.m. snack, lunch, p.m. snack, dinner, and HS snack.
06/08/25: P5 refused breakfast, a.m. snack, lunch, p.m. snack, dinner, and HS snack.

c. P5 medical record indicated on 06/02/25 provider note indicated: An order for P5 to receive Fosfomycin 3 gram every 72 hours, 3 doses from 06/02/25 to 06/09/25 based on 05/30/25 lab results of leukocytosis and urinalysis findings. On 06/04/25 psych Nurse Practitioner (NP), noted P5 was agitated this morning and using restroom frequently. The NP inquired to find out why P5 had not received Fosfomycin yet. The medication time was adjusted in the computer, and they asked the Registered Nurse (RN) to give the first dose now. The Unit Manager and Director of Nursing (DON) are aware, regarding antibiotic missed dose.

3. Review of P1 medical record indicated the following:
a. Medical record lacked documentation of provider notification of weight loss of 5 lbs (pounds) or more in one week. Review of P1's biometrics as follows:
07/12/25: 3:43 a.m., P1 weighed 158.6 lbs.
07/14/25: 7:42 a.m., P1 weighed 151.2 lbs.

b. P1's medical record lacked documentation of weight being obtained at least three times per week. Review of
P1's biometrics as follows:
06/24/25: 7:15 p.m., P1 weight of 160.8 lbs.
06/28/24: 8:01 a.m., P1 weighed 162 lbs.

4. Review of P2 medical record indicated the following:
a. Medical record lacked documentation of provider notification of weight loss of 5lb or more in one week. Review of P2's biometrics as follows:
07/03/25: 6:27 a.m., P2 weighed 184.4 lbs.
07/05/25: 7:10 a.m., P2 weighed 164.4 lbs.

b. P2's medical record lacked documentation of weight being obtained at least three times per week.
Review of P2's biometrics as follows:
06/23/25: 12:27 a.m., P2 weighed 188.8 lbs.
06/29/24: 7:00 a.m., P2 weighed 185.8 lbs.

5. P3's medical record lacked documentation of provider notification of weight loss of 5lb or more in one week and weight being obtained at least three times per week.
Review of P3's biometrics as follows:.
05/26/25: 8:43 a.m., P3 weighed 114.4 lbs.
06/04/24: 7:30 a.m., P3 weighed 108.2 lbs.

6. Review of P4 medical record indicated the following:
a. Medical record lacked documentation of provider notification of weight loss of 5lb or more in one week. Review of P4's biometrics as follows:
05/31/25: 5:21 a.m., P4 weighed 180.2 lbs.
06/03/25: 7:12 a.m., P4 weighed 173.4 lbs.

7. Interview with A1 (Chief Executive Officer [CEO]) on 07/23/25 at approximately 3:35 p.m., confirmed P1, P2, P3, P4, and P5 medical record information related to weights and nutrition.