Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to follow physician orders regarding the notification of a physician or nurse practitioner when a resident experienced significant weight gain. The resident, who had multiple diagnoses including hypertension, type 2 diabetes with neuropathy, chronic kidney disease, and cardiac pacemaker, had a physician order in place to weigh daily and notify the physician if there was a weight gain of three pounds in a day or five pounds in a week. Despite documented weight increases exceeding these thresholds on two occasions, there was no evidence that the physician was notified as required. Interviews with nursing staff and the Director of Nursing confirmed that the expected notifications did not occur and could not be found in the resident's records.