Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident who experienced unintentional weight loss. The resident, who had diagnoses including dementia and dysphagia, was dependent on staff for feeding assistance and was not on a physician-prescribed weight loss regimen. Documentation showed the resident lost 5.2 pounds, or 5.18% of body weight, over a one-month period. Despite this significant weight loss, there was no evidence in the medical record that the physician had been notified, as required by facility policy and standard practice. Interviews with licensed nursing staff and the infection preventionist confirmed that a weight loss of 5 pounds in a month, especially for a resident weighing under 100 pounds, constitutes a significant change of condition that should be reported to the physician. The staff acknowledged that this notification did not occur, and there was no care plan indicating that weight monitoring or reporting should be discontinued, even though the resident was on hospice services. The facility's policy also required physician notification for such weight variances, but this was not followed in this case.