Failure to Timely Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely notify a physician of a significant weight change in a resident with diagnoses of congestive heart failure and chronic kidney disease. According to the facility's policy, significant weight changes require prompt reweighing and physician notification. The resident had a physician's order to be weighed three times a week to monitor for weight gain due to edema. A review of the resident's records showed a 20-pound (9.22%) weight gain over five days, but the resident was not reweighed until five days after this significant change was identified. Additionally, there was no documentation that the resident was assessed upon identification of the significant weight gain, nor was there evidence that the physician was notified until several days later. The Director of Nursing confirmed that the physician was not notified in a timely manner regarding the resident's significant weight gain, which was contrary to facility policy and regulatory requirements.