Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
Facility staff failed to notify the physician of a significant change in condition for one resident who experienced notable weight gain. The resident had multiple diagnoses, including diabetes, atherosclerosis, peripheral vascular disease with a left below-knee amputation, gastroesophageal reflux disease, essential hypertension, and major depressive disorder. Clinical records showed that the resident's weight increased from 127.5 lbs to 146 lbs within a little over a month, and from 126.8 lbs to 153 lbs over six months, representing a 14.51% and 20.66% gain, respectively. The Minimum Data Set (MDS) assessment identified these as significant weight gains. Although the Registered Dietician reviewed each significant weight gain and updated the care plan accordingly, there was no evidence found in the clinical record that the primary care provider was notified of these changes. The facility's own policy required physician notification in the event of significant weight changes. During interviews and document reviews, the Director of Nursing confirmed that no documentation existed to show the provider had been informed, and no further information was provided to the survey team before the exit conference.