Failure to Notify POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify the medical power of attorney (POA) for a resident who experienced significant weight loss. Medical record review showed that the resident, who had diagnoses including aspiration pneumonia, COPD, prostate cancer, type 2 diabetes, moderate protein-calorie malnutrition, and dementia with behavioral disturbance, had severely impaired cognition and was dependent on staff for most activities of daily living. The resident's weight dropped from 146.2 pounds to 129.8 pounds and then to 109 pounds over a short period, representing a loss of more than 25% in one month. Despite these significant changes, there was no documentation that the resident's POA was notified of the weight loss events on multiple occasions. Staff interviews confirmed that the registered dietitian had not informed the POA about the resident's weight changes, with the last contact occurring during a care conference prior to the documented weight loss. Facility policy required notification of the POA for any weight change of 5% or more from the last weight, defining severe weight loss as greater than 5% in one month or 10% in six months. The lack of notification was verified through medical record review, staff interview, and policy review.