Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to notify the medical provider of significant weight changes, as ordered, for a resident with multiple complex medical conditions, including chronic systolic heart failure, renal insufficiency, end stage renal disease, and non-Alzheimer's dementia. The resident was on a diuretic and had specific physician orders requiring daily weights and immediate provider notification for a weight gain of 3 pounds or more in one day, or a loss of 3 pounds in one day. Clinical record review showed multiple instances where the resident's weight fluctuated by 3 pounds or more within a day, but there was no documented evidence that the provider was notified of these changes as required by the physician's order and facility policy. Staff interviews revealed inconsistent practices regarding provider notification and documentation. One LPN stated she notified the doctor via text message but did not document this in the resident's progress notes and deleted the messages after receiving a response. Another LPN claimed to have notified the provider and documented it, while the RN Unit Manager indicated that such notifications should be found in progress notes or paperwork submitted to the provider. The Director of Nursing confirmed that staff should notify the doctor after reweighing the resident and that the Unit Manager is responsible for auditing and educating staff. Facility policies reviewed required that active orders be followed and that significant changes in a resident's condition be immediately communicated to the provider.