Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for one resident, as required by both facility policy and the resident's care plan. The resident experienced a weight decrease from 126.1 pounds to 109.4 pounds within a month, which was documented in the vital sign records and noted by the dietitian, who recommended nutritional interventions. However, there was no documentation that the physician was informed of this significant change, and the dietitian's recommendation form was not signed by the physician. Interviews with staff revealed confusion regarding responsibility for physician notification, and the Director of Nursing confirmed that no contact had been made with the physician regarding the resident's weight loss.