Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to immediately notify a resident's physician of a significant change in the resident's physical status, specifically a substantial weight loss of 25.8 pounds within 30 days. The resident in question had multiple diagnoses, including cerebral palsy, dysphagia, and lack of coordination, and was assessed as being moderately impaired for daily decision making and rarely or never understood. Despite the significant weight fluctuation documented in the electronic medical record, there was no evidence in the progress notes that the primary care physician was informed of these changes. Interviews with facility staff revealed that the process for monitoring and reporting weight variances involved several steps, including weighing by CNAs, data entry by charge nurses, and review by the ADON, who was responsible for notifying the physician, responsible party, and dietician. However, the ADON had recently been relieved of duties, and the DON, who had just assumed responsibility, was unaware of the resident's weight variance until the survey. The facility's policy required timely notification and documentation of significant weight changes, but this was not followed in this instance.