Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify both the physician and the resident's representative of a significant change in a resident's condition, specifically a substantial weight loss. According to the facility's policy, licensed nurses are required to notify the physician and the resident's responsible party of significant weight changes and document this notification in the progress notes. For one resident with a history of traumatic brain injury and persistent vegetative state, weight records showed a loss of over 25% of body weight within a short period. However, a review of the resident's progress notes from the time of the weight loss did not show any documentation that the physician or the resident's representative had been notified. Interviews with facility staff, including the Registered Dietitian and the Assistant Director of Nursing, confirmed that it was the responsibility of the Resident Care Manager to notify the physician and the resident's representative in such cases, and that this should be documented in the medical record. The resident's representative also stated they were not informed of the significant weight loss. The lack of notification and documentation was confirmed through joint record reviews and staff interviews.