Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's responsible party after a significant weight loss was identified. According to facility policy, significant unplanned weight loss must be promptly communicated to the resident, their legal representative, and the attending physician. In this case, a male resident with multiple diagnoses, including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, experienced a severe weight loss of 13.2% in one month, as documented in the facility's records. The resident's Minimum Data Set (MDS) assessment also confirmed significant weight loss not associated with a physician-prescribed regimen. Despite these findings, there was no documentation in the electronic medical record that the resident's guardian was notified of the severe weight loss. The guardian confirmed during an interview that she was not informed of the weight loss and expressed a desire to be kept updated due to her involvement in the resident's care. The Regional Director acknowledged that it was the Director of Nursing's responsibility to notify the family and could not find any evidence that such notification occurred.