Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to address significant weight discrepancies for one resident with multiple medical conditions, including heart failure, a femur fracture, and vascular parkinsonism. The resident was under physician orders for daily weights and required notification to the physician if there was a weight gain of 3 pounds or more overnight or 5 pounds in one week. Despite this, multiple instances were documented where the resident experienced weight gains ranging from 3.6 to 12 pounds in less than 24 hours, and there was no evidence in the record that the physician was notified as required by the orders. Interviews with nursing staff and the Director of Nursing revealed that while staff were generally aware of the need to re-weigh residents or notify the physician in the event of significant weight changes, these actions were not consistently documented or performed. The DON acknowledged that monitoring of weight discrepancies had lapsed due to other responsibilities, and the facility's policy required reporting significant weight changes to the nurse supervisor and in accordance with professional standards, which was not followed in these instances.