Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's physical status, specifically regarding unplanned weight loss. Resident #30, who had diagnoses including Parkinson's disease, diabetes, and gastro-esophageal reflux disease, experienced a notable weight loss over a period of three months. Despite the facility's policy requiring notification of the physician in such cases, there was no documented evidence that the physician was informed of the resident's weight loss. The resident's weight decreased from 160 pounds in October 2024 to 139 pounds by January 2025, indicating a 13.1% weight loss over three months. The facility's care plan included monitoring the resident's nutritional status and implementing dietary interventions, such as providing Ensure Plus high protein supplements. However, the physician was not notified of the resident's significant weight loss, as confirmed by interviews with the dietetic technician and the registered nurse unit manager. Interviews with facility staff revealed a breakdown in communication and documentation processes. The dietetic technician and registered nurse unit manager both indicated that they relied on established procedures for communicating weight changes, which involved passing information through various staff members. However, the physician was not informed of the resident's weight loss, and there was no documentation in the resident's chart regarding the weight change. The physician stated they expected to be notified of significant weight changes, but this did not occur in this instance.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F580- Notify of Changes: Crouse Community Center will ensure that the physician is notified when there is a significant change in the resident’s physical, mental, or psychosocial status with, potentially, the need to alter treatment. Corrective action: The facility will ensure that the physician is notified with any significant change in condition with a focus on unplanned weight loss. For resident #30, the physician was notified of the weight loss by the nurse manager. A significant change in status assessment was initiated due to the resident’s change in status in order for the IDT and family to establish appropriate goals of care. Diet consistency and level of assist with eating was changed as the immediate intervention with high protein supplements added by dietary. Resident transitioned to comfort care and expired on [DATE]. Other residents: The physician has reviewed and documented on all residents who had significant weight changes (5%/month or 10%/6months) in order to ensure adequate treatment. Systemic changes: All licensed staff will be re-educated on our Change in Condition-Notification policy, and Weight policy. Focus will be on significant weight loss and timely notification. The facility will ensure that the physician is notified with any significant change in condition with focus on unplanned weight loss. Monitoring: Audits will be conducted by Director of Nursing monthly with a 100% compliance threshold and reported to QAPI monthly. Responsible Party: Director of Nursing