Failure to Timely Notify Physician, Dietitian, and Representative of Severe Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician, dietitian, and representative in a timely manner after the resident experienced a severe weight loss. The resident lost 27 pounds, representing an 11.86% decrease in body weight over a three-month period, with a 20-pound loss occurring in less than two months. Documentation in the medical record did not show immediate notification to the physician, dietitian, or the resident's representative regarding this significant change. Nursing progress notes indicated that the medical physician was only notified of the weight loss during a routine 90-day visit, and the dietitian was consulted several days later. The resident's guardian was informed after the fact, and attempts to reach the family were not immediately successful. Staff interviews confirmed that awareness of the weight loss occurred only in the days leading up to the notification, and there was a delay in obtaining a reweigh when a significant weight difference was first noted.