Failure to Notify Practitioner of Significant Weight Changes
Penalty
Summary
Facility staff failed to notify the medical practitioner of significant changes in a resident's daily weights, as required by both facility policy and physician orders. The resident, who was cognitively intact and had a diagnosis of heart failure, had orders in place for daily weights with instructions to call the physician for any weight increase of 1 to 5 pounds. Despite this, the medical record review showed multiple instances where the resident experienced weight gains exceeding the notification threshold, including an 8.6-pound increase in one day and other increases of 6.7, 3.9, and 3.8 pounds on separate occasions. There was no documentation that the practitioner was informed of these changes. Interviews with the Director of Nursing confirmed that the practitioner was not notified of the significant weight increases, despite the clear orders and facility policy requiring such communication. The lack of notification was corroborated by the absence of related documentation in the resident's progress notes, faxes, and practitioner orders. The deficiency was identified through record review and staff interviews, which established that the required notifications did not occur as specified.