Failure to Notify Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the designated representative of a resident's significant weight loss, as required by its own policy and regulatory standards. The resident in question had multiple diagnoses, including end stage renal disease and stage 2 and 3 pressure ulcers. The resident experienced a weight loss of more than 5% in one month, as documented in both the weight monitoring records and dietary notes. Despite this significant change, there was no documented evidence in the medical record that the resident's representative was informed of the weight loss. Interviews with facility staff, including a registered nurse, social worker, and dietitian, revealed that each believed the responsibility for notifying the representative lay with another staff member. The dietitian confirmed that the weight loss was significant and that notification should have occurred, but upon review of the dietary notes, found no documentation of such notification. The administrator also acknowledged that notification and documentation were required in cases of significant weight change, but confirmed that this did not occur for the resident.