Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to comply with the requirement to notify a physician of significant changes in a resident's condition. Specifically, the facility did not inform the physician about a significant weight loss experienced by a resident. The resident's weight dropped from 192.3 pounds on August 2, 2024, to 178.0 pounds on October 8, 2024, indicating a 7.4 percent weight loss. This significant change in the resident's physical status was not communicated to the physician, as confirmed by the review of the clinical records. During an interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that the physician was not notified of the resident's weight loss. This oversight was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance Survey, and three complaint investigations completed on April 25, 2025. The deficiency was noted under the federal regulation 42 CFR Part 483, Subpart B, and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulation.
Plan Of Correction
1. The physician was notified of Resident 34 significant weight loss on 05/01/2025. No new orders at that time. 2. Facility audit was completed to determine if any other residents trigger for significant weight loss, and none determined. 3. DON, or designee will educate nursing staff on obtaining resident weights as ordered and will educate nursing staff on weight policy. 4. DON, or designee, will randomly audit resident weights weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.