Failure to Notify MD and Initiate Change of Condition for Significant Weight Loss
Penalty
Summary
The facility failed to notify the Medical Doctor (MD) and create a Change of Condition (COC) for a resident who experienced a significant unplanned weight loss of 17 pounds within one month. The resident, who had diagnoses including dementia and dysphagia, was noted to have severe cognitive impairment and required set up assistance with eating. Despite documentation in the progress notes and care plan indicating the weight loss and the need for immediate notification of the physician and dietitian, there was no evidence that the MD was informed or that a COC was created at the time of the weight loss. Interviews with facility staff, including a Registered Nurse Supervisor, Licensed Vocational Nurse, Registered Dietitian, and Director of Nursing, confirmed that the MD was not notified of the resident's weight loss, and no COC was initiated. The facility's policies required staff to notify the MD of significant changes in a resident's condition, including substantial weight loss. The failure to follow these procedures meant that necessary interventions to address the resident's nutritional status were not implemented in a timely manner.
Plan Of Correction
F692: Nutrition/Hydration Status Maintenance CORRECTIVE ACTION On 3/27/25 the Primary MD was notified of the 17lbs weight loss and COC was initiated. OTHER RESIDENT AFFECTED IDENTIFICATION All residents had the potential to be affected by the alleged deficient practice. On 3/27/2025, the RD checked all residents with significant weight change since 2/1/2025 until 3/28/2025 and found 3 residents that did not have a COC and MD was not notified of the significant change. On 3/28/2025, the charge nurse started a COC and notified the physician. MEASURES AND SYSTEMIC CHANGES DON/Designee provided in-service to license nurses 3/25/25 Re: importance of notifying MD and initiating a change of condition when weight changes (weight loss/weight gain) were identified on residents including notification of RP and RD for proper interventions to prevent further weight loss. DON/Designee provided in-services 3/25/25 to License nurse/RNA, dietary Staff re: importance of obtaining weight including timeliness of MD/RP notification and initiating change of condition. Re: weight loss. During the weekly weight meeting, RD will discuss any significant weight changes with the IDT and the nursing representative will verify and start the COC and notify the MD for further orders as needed. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.