Failure to Notify PCP of Significant Weight Gain
Penalty
Summary
The facility failed to notify the primary care physician (PCP) of a significant weight gain in a resident with severe cognitive impairment and multiple comorbidities, including hypertension, diabetes, Alzheimer's disease, and obstructive sleep apnea. The resident experienced a weight increase from 252 lbs to 292 lbs, representing a 15.87% gain over several months. Documentation showed that the registered dietitian (RD) identified the weight gain as likely not nutrition-related and communicated concerns to nursing staff via email and progress notes. Nursing staff performed cardiac and fluid status assessments but did not update the PCP regarding the ongoing and significant weight gain. Interviews with facility staff, including the RN case manager and the director of nursing (DON), confirmed that the expectation was for nursing to notify the PCP in cases of significant weight changes. Despite repeated notifications from the RD and internal assessments, there was no evidence that the PCP was informed of the resident's 40 lb weight gain. Facility policy required prompt rechecking and follow-up for notable weight changes, but the lack of communication with the PCP constituted a failure to provide appropriate treatment and care according to orders and the resident's needs.