Failure to Notify Provider and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Advanced Practice Registered Nurse (APRN) and family or responsible party of significant, unplanned weight loss in two residents. In the first case, a resident with diagnoses including dysphagia, dementia, and a history of pressure wounds experienced a weight loss of over 10% in less than one month. The resident's care plan included monitoring for nutritional problems and regular weight checks. Despite documentation of the weight loss and a subsequent reweight confirming the loss, there was no evidence that the APRN or family were notified at the time the loss was identified. Interviews with nursing staff, the APRN, and the Director of Nursing confirmed that the expected notifications did not occur, and the APRN was unaware of the weight loss until much later. In the second case, another resident with dysphagia, aphasia, and diabetes mellitus was to be weighed weekly per physician's orders. The resident experienced a significant weight loss of over 14% in two weeks, but the only weights recorded were at the start and end of this period. The APRN and physician were not notified of the severe weight loss, and the dietician initiated a reweight order without provider notification. Interviews with nursing staff and APRNs confirmed that neither was aware of the weight loss, and the facility's own policies requiring provider and family notification were not followed. Facility policies directed that significant weight changes should be confirmed with a reweight and communicated to the dietician, provider, and family. In both cases, documentation and interviews revealed that these steps were not taken as required. The failures were identified through review of clinical records, facility documentation, and staff interviews, which consistently showed a lack of timely notification to the appropriate parties regarding significant changes in residents' conditions.