Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident on two separate occasions, as required by facility policy. The resident, who had intact cognition and multiple comorbidities including CHF, diabetes, COPD, morbid obesity, gout, hypothyroidism, and hyperlipidemia, experienced a weight loss of over 10% in six months and over 5% in one month. Documentation showed that the dietitian identified and documented the significant weight loss and made recommendations, including meal enrichment and weekly weights, and noted that faxes were sent to the clinician. However, the facility was unable to provide documentation that the physician was actually notified or made aware of the weight losses, despite multiple staff interviews and record reviews. The resident's care plan and dietary notes reflected ongoing monitoring and interventions for nutritional risk, including the use of supplements and meal enrichment strategies. The resident herself was aware of her weight loss and attributed it to poor appetite following her husband's death and a recent illness. Despite these interventions and awareness by dietary staff, there was no evidence in the medical record or from staff that the physician was notified of the significant changes in the resident's condition, as required by the facility's policy on change in condition.