Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for two out of three residents reviewed for physician notification. Specifically, one resident with a history of cerebrovascular accident, diabetes mellitus, contractures, and muscle wasting experienced a significant unplanned weight loss. The resident's weight dropped from 222.4 pounds to 207 pounds within a month, representing a 6.92% loss of body weight. This weight loss was documented in the clinical record and noted by the dietary staff, who identified the loss as significant according to facility policy and clinical guidelines. Despite the documentation of this significant weight loss and the facility's policy requiring physician notification for such changes, there was no evidence in the electronic health record that the physician was notified. The Director of Nursing confirmed during an interview that it is expected for the physician to be notified of significant weight loss. The facility's policy also clearly states that the medical doctor and registered dietician should be notified when a significant weight change is identified.