Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident with multiple diagnoses, including chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia. The resident was severely cognitively impaired and required varying levels of assistance with activities of daily living. Medical record review showed a substantial decrease in the resident's weight over several months, with weights dropping from 135.6 pounds to 87.8 pounds. There were also several months where the resident was not weighed, and some recorded weights were identified as inaccurate or missing. The registered dietician noted the need for reweighing and recognized the significant weight loss but was unable to implement nutritional interventions due to the lack of accurate data. Interviews with facility staff, including the DON and the RD, confirmed that they were unaware of the extent of the resident's weight loss and that there were gaps in weight documentation. The physician stated she was not notified of the resident's weight loss or the inconsistent weight monitoring. There was no documented evidence in the medical record that the physician had been informed of the resident's significant weight loss, and no nutritional interventions were put in place to address the issue.