Failure to Notify Physician and Obtain Assessment for Significant Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a physician was notified and completed an assessment regarding a resident's significant unplanned weight loss. Clinical record review for a resident with diagnoses including muscle wasting, atrophy, dysphagia, and dementia showed multiple instances of significant weight loss over several months. Documentation indicated that the resident experienced a rapid and substantial decrease in weight, with notes questioning the accuracy of the measurements and suggesting possible scale discrepancies. Despite ongoing poor intake, changes in diet, and continued weight loss, there was no documented evidence that the physician was informed or that a medical evaluation was conducted to determine the causes of the weight loss. Interviews with facility staff, including the Regional Director of Nursing, confirmed that the resident's physician had not been notified and had not documented any assessment related to the significant weight loss. The clinical records lacked any indication of physician involvement or evaluation in response to the resident's ongoing and clinically significant weight changes. This failure to notify and involve the physician was cited as a violation of state regulations regarding nursing and physician services, as well as clinical record requirements.