Failure to Notify Physician of Significant Weight Loss Prior to Discharge
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically a notable weight loss, prior to the resident's discharge. According to facility policy, residents are to be weighed regularly, and any weight change of 5% or more within 30 days is considered significant and requires physician notification. The resident in question, who was cognitively intact and recovering from recent fractures, experienced a 5.52% weight loss over 13 days. The weight loss was documented in the electronic medical record, but there was no evidence of a re-weigh to confirm accuracy or any notification to the physician regarding this significant change. The facility's policies also require immediate physician notification for significant changes in a resident's physical status. Despite these protocols, the DON confirmed during interview that she was unaware of the re-weigh procedure and could not provide evidence that the physician or nurse practitioner had been informed of the resident's weight loss. The resident was discharged home without the physician being notified of the significant weight loss, and this lapse was identified during a review of the medical record and interviews with facility staff.