Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to follow its policy and procedure regarding notification of a change in a resident's condition or status. Specifically, staff did not notify a resident's physician of a significant unintentional weight loss, as required by facility policy. The resident experienced a weight decrease from 144 pounds to 127 pounds over a 30-day period, which was documented in the progress notes. Despite this significant weight loss, there was no Change in Condition Evaluation created for June, July, or August, and the physician was not notified of the change. The resident involved had multiple medical diagnoses, including multiple rib fractures, hypertensive heart disease, urinary tract infection, and protein-calorie malnutrition. The resident was assessed as having moderate cognitive impairment and required varying levels of assistance with activities of daily living. Facility policies required staff to report significant weight changes to the physician, but review of records and interviews with nursing staff and the DON confirmed that this notification did not occur for the resident's significant weight loss.