Failure to Notify Physician and Intervene After Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and implement timely interventions following a significant weight loss in a resident with multiple medical conditions, including hemiplegia, dysphagia, and chronic pain syndrome. The resident was dependent on staff for eating assistance and had a feeding tube, with severely impaired cognition. Despite care plan directives and physician orders to monitor weights and notify the provider of significant changes, the facility did not clarify discrepancies in recorded weights, did not document a weight during a required week, and did not notify the physician of a substantial weight loss from 166 lbs to 150 lbs over eight days. There was also no documentation of interventions to address the weight loss prior to eventual physician notification. Staff interviews revealed a lack of clarity regarding which weight measurements were accurate and inconsistent monitoring and follow-up on significant weight changes. The Registered Dietician was on leave during the period in question, and the substitute RD did not monitor or document weight changes as required. The facility's policy required physician notification and individualized care plan interventions for significant weight changes, but these actions were not documented or carried out in a timely manner for the resident.