Failure to Notify Responsible Parties of Significant Weight Loss
Penalty
Summary
St. Joseph's Manor was found to be non-compliant with federal and state regulations regarding the notification of changes in resident conditions. Specifically, the facility failed to notify the responsible parties of two residents about significant weight loss. According to the facility's policy titled "Weight Management Guidelines," nursing staff are required to report unexplained significant weight changes to the family or responsible party. However, this protocol was not followed for two residents, identified as CL1 and 3, who experienced notable weight loss over a period of time. Resident CL1, who had Alzheimer's dementia and dysphagia, experienced a six percent weight loss from February to March 2025, dropping from 178.6 lbs to 167.8 lbs. Similarly, Resident 3, also diagnosed with dementia and dysphagia, lost 5.4 percent of their body weight between January and February 2025, with the weight loss persisting into March. Despite these significant changes, there was no documented evidence that the families or responsible parties of these residents were informed, as confirmed by the facility's Administrator during an interview.
Plan Of Correction
*What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? It has always been our policy and practice to notify families of significant change. In this case, the family was here each day with the resident and was up to date on the resident's condition. However, the nursing staff interacted with them verbally on a daily basis and they did not write nursing notes about those interactions. The patient is no longer at the center, so no further follow-up is needed for the resident. *How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other resident notification needs were identified during the recent audit. *What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? Staff in-service is being provided regarding: when to notify families, what constitutes a change in condition, and how to document those notifications. *How the corrective action will be monitored to ensure that the deficient practice will not recur, i.e., what quality assurance programs will be established? RNACS send out change of status (sig change notice) and other change of condition would be identified on shift reports. We will ask unit managers to monitor those and assure family is notified. DON or her designee will also monitor changes in condition and assure family was notified during morning clinical meeting.