Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight changes in a resident with dementia and severely impaired cognition. The resident was admitted with a weight of 135-136 pounds and was noted to have no known weight loss at admission. Over the course of several months, the resident experienced a significant weight loss, dropping to 120 pounds as documented in the quarterly Minimum Data Set. The care plan indicated that the resident made her own food choices, was on a liberalized geriatric diet, and required staff to cue her for meals and encourage fluid and snack intake. Weights were to be recorded weekly, and the facility policy required the nursing director to notify the physician of significant weight loss. Despite these interventions and policies, the electronic medical record showed a progressive decline in the resident's weight, with no evidence that the physician was notified after weights of 127.5 pounds and 119.5 pounds were recorded. The registered dietician documented limited meal intake, with most meals consumed at less than 26% and only 14 meals charted over two weeks. Staff reported the resident often preferred to stay in her room, slept late, and declined meal and snack offers, stating she was not hungry. The dietician recommended considering an appetite stimulant due to the ongoing weight loss and poor intake, but there was no documentation that these recommendations or the significant weight loss were communicated to the physician in a timely manner. Interviews with staff revealed a lack of clarity regarding the process for notifying the physician about weight loss and following up on the dietician's recommendations. The administrative nurse stated that the dietician provided a weekly list of residents with weight loss and that nurses were responsible for discussing recommendations with the physician. However, the consultant physician confirmed she was not notified of the resident's weight loss until much later, at which point she ordered nutritional supplements. The facility's failure to promptly notify the physician of the resident's significant weight loss constituted the identified deficiency.