Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding a significant change in the resident's physical status, specifically a weight loss of 7.2 pounds over 14 days. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus, was moderately cognitively impaired and required substantial to maximal assistance with activities of daily living. The weight loss was documented in the resident's records, but there was no evidence that the physician was informed of this significant change. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the weight loss met the facility's criteria for a significant change, which should have triggered physician notification and an interdisciplinary review. The facility's policy required staff intervention and care plan revision for such changes, but documentation and staff statements indicated that the physician was not made aware, and the resident was not reassessed in response to the weight loss.