Failure to Notify Responsible Parties and Physicians of Significant Weight Changes
Penalty
Summary
The facility failed to notify resident representatives and physicians of significant weight changes in multiple residents, as required by policy and physician orders. For three residents with cognitive impairment and designated representatives, there was no documentation that the responsible party was informed of substantial weight loss, despite clear evidence in the clinical record and dietician notes of weight declines exceeding 5% in one month or 10% in six months. In each case, the care plans and facility protocols required notification, and staff interviews confirmed that nurses were responsible for this communication, yet the notifications were not documented. One resident with congestive heart failure had physician orders specifying that the physician should be notified of a weight gain of 3 pounds in 24 hours or 5 pounds in one week. Despite documented weight gains meeting these criteria, there was no evidence that the physician was notified. Staff interviews confirmed awareness of the protocol and the expectation to notify the physician, but could not provide documentation that this occurred. The facility's heart failure protocol and weight monitoring policy both required timely reporting of significant weight changes to the physician and family. The deficiency was identified through review of clinical records, facility documentation, and staff interviews. The lack of notification was confirmed by the absence of progress notes or other documentation in the electronic medical record, as well as direct statements from staff that notifications had not been made. The facility's own policies and protocols, as well as physician orders, were not followed in these instances, resulting in a failure to communicate significant changes in resident condition to the appropriate parties.