Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
Facility staff failed to notify the physician of a significant weight loss in a resident, as required by facility policy. The resident, who had diagnoses including Amyotrophic Lateral Sclerosis, quadriplegia, and ileus, experienced a 14 percent weight loss over less than two months. The weight record showed a drop from 69 kilograms to 59.9 kilograms, and the resident had refused to be weighed in the intervening month. This significant weight loss was not identified or communicated to the physician in a timely manner. Interviews with facility staff, including a registered dietitian, nurse informatics, a registered nurse, and a case manager, confirmed that there was no documentation of physician notification regarding the weight loss. The facility's policy required that a weight variance of five pounds or more be communicated to the physician and registered dietitian for further review. The lack of notification resulted in a delay in altering the resident's treatment.