Failure to Notify Physician and POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify both the physician and the resident's Power of Attorney (POA) of a significant change in condition for one resident. The resident, who had diagnoses including stage 4 pressure ulcer, severe protein-calorie malnutrition, type 2 diabetes, adult failure to thrive, dementia, cognitive communication deficit, and dysphagia, experienced a documented weight loss of 22.2 pounds (an 11.62% decrease) within one month. This weight loss was identified through the facility's weights/vitals records, and the Dietary Manager confirmed the significant loss after requesting and receiving two reweighs that confirmed the same result. Despite the facility's policies requiring notification of significant weight loss (defined as greater than 5% in 30 days) to both the physician and the resident's representative, there was no documentation that either party had been informed. Interviews with the resident's POA, physician, and nurse practitioner confirmed that none had been notified of the weight loss. The Director of Nursing also acknowledged that such notification should have occurred according to facility policy.