Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain in a resident with diagnoses including edema, non-Alzheimer's dementia, and major depressive disorder, whose cognition was severely impaired. The resident's weight increased from 158 lbs. to 180 lbs. over approximately two months, representing a 13.92% gain. Although a quarterly nutritional assessment noted the weight gain and recommended a reduction in supplement intake, there was no documentation that the provider was notified of the continued weight increase during this period. Staff interviews confirmed that both the RN and DON would expect provider notification in such cases, and facility policy required physician consultation for significant changes in condition or treatment needs.