Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
A resident experienced a significant and severe weight loss, losing 60 pounds over six months and 26 pounds in the last month, as documented in the electronic health record. Despite this marked decline, the medical provider was not notified of the weight loss, which prevented the physician from having the opportunity to plan or implement interventions. Interviews with staff revealed that while the resident's family was aware of the weight loss, several staff members were unaware of the extent of the decline, and the responsible staff member admitted to not notifying the physician as required. The facility's policy required that all significant changes in weight be reported to the resident's provider, specifically noting thresholds of 5% in 30 days or 10% in 180 days. The resident had been admitted to the Nutrition at Risk Committee, and a note in the record indicated that the care manager was to notify the provider of the weight loss. However, this notification did not occur, as confirmed by staff interviews and record review.