Failure to Timely Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to timely notify the physician of a significant change in a resident's condition, specifically a notable weight loss. According to the facility's policy, a weight loss of more than 5% in one month is considered significant and requires physician notification. A resident with dementia and a femur fracture experienced an 8.98% weight loss in less than a month, dropping from 153.6 pounds to 139.9 pounds. The dietitian's assessment noted the weight loss and decreased oral intake, and nursing progress notes confirmed the weight was taken twice to verify accuracy. Despite these findings, clinical records did not show that the physician was notified of the significant weight loss until three weeks after it was identified. The DON confirmed that it was the nurses' responsibility to inform the physician, but this was not done in a timely manner. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.