Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to immediately notify the physician and resident representative of significant changes in physical condition for two residents reviewed for nutrition. In the first case, a resident with severe cognitive impairment experienced a significant weight loss, dropping from 111.6 lbs to 85.8 lbs over several months, representing a loss of over 23%. The resident's Durable Power of Attorney (DPOA) was not informed of this weight loss, and both the provider and Registered Dietitian (RD) were also not notified, as confirmed by staff review of the electronic health record (EHR). The DPOA only became aware of the weight loss after noticing physical changes and was concerned about the lack of communication from the facility. In the second case, another resident with dementia experienced a weight loss of over 6% in one month and nearly 8% in three months. The resident's family member noticed the weight loss and expressed concern. The resident's weight was recorded in a weight binder but was not entered into the EHR in a timely manner, which delayed notification to the power of attorney and provider. Staff confirmed that the expectation was for weights to be entered into the EHR on the same shift and for notifications to be made, but this did not occur for this resident.