Physician Failed to Document Significant Weight Loss
Penalty
Summary
A physician failed to document a note addressing a significant weight loss in a resident, as identified during a review of medical records and staff interviews. The resident experienced a weight decrease from 135.8 lbs to 109 lbs over a six-month period, amounting to a 19.73% loss. The dietitian recognized the weight loss as significant and documented that the interdisciplinary team, Medical Director, and resident representative were informed. However, a review of the physician's notes revealed no documentation addressing the weight loss following the notification. The facility's weight monitoring policy states that providers should document diagnoses or clinical conditions contributing to significant weight loss. Despite this, the only provider note available after the weight loss did not address the issue. Interviews with the DON and Medical Director confirmed that the physician did not document an updated plan of care or address the significant weight loss in the resident's medical record, even though the expectation was for such documentation to occur.