Failure to Promptly Notify Clinicians and Intervene for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician and Registered Dietician (RD) of a significant weight loss and to initiate timely nutritional interventions. The resident had severe cognitive impairment, was dependent on enteral tube feeding, and had been assessed as malnourished. Weight records showed a drop from 121.4 lbs to 96.9 lbs, then to 94 lbs and 92.8 lbs over a short period, reflecting approximately a 20% weight loss within two weeks. Nursing documentation noted that the nurse informed the resident’s power of attorney about the weight loss and discussed plans to increase tube feeding volume and rate, clarifying that the resident was on a total volume regimen rather than continuous feeding. However, there was no documentation that the physician or RD were notified at the time the significant weight loss was identified. The RD stated that she was not notified of the resident’s weight loss until she independently pulled the weight and vitals exception report prior to a scheduled weight meeting, and that she does not always receive direct notification of significant weight changes. The DON explained that the documentation system triggers for significant weight changes and that such changes should be brought to management the day they are noted so that the nurse practitioner and RD can be notified and recommendations obtained. The DON further stated that staff are supposed to notify the RD and physician immediately when there is a weight change, especially for residents on tube feeding who are at high risk for weight fluctuations, and acknowledged that in this case notification occurred days later. The facility’s policy on significant weight loss defined thresholds for significant loss and required assessment by a licensed dietician, but the resident experienced a 28.6 lb loss within two weeks with no documented nutritional interventions for five days following the identified weight loss.
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