Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely notification of significant weight loss to the physician and/or resident representative for two residents. For one resident with diagnoses including dementia, failure to thrive, dysphagia, Alzheimer's disease, and moderate protein-calorie malnutrition, weight records showed fluctuations and a notable decrease. Although the nutrition note acknowledged the weight loss and indicated ongoing monitoring, there was no documentation that the physician, nurse practitioner, or resident representative had been notified. The diet technician was unsure if the family had been informed and confirmed that no documentation of such notification existed. The nurse practitioner also stated she was unaware of the weight loss and would have assessed the resident if notified. For another resident with a history of cerebrovascular infarction, traumatic subdural hemorrhage, multiple fractures, gastrostomy, dysphagia, and moderate protein-calorie malnutrition, weight records indicated a significant decrease over several months. Progress notes mentioned a discussion with the resident's mother about the weight loss and plans for weekly monitoring, but there was no documentation of notification to the physician or nurse practitioner. The facility's policy requires prompt notification of the resident, attending physician, and representative regarding changes in condition or status, but this was not followed in these cases.