Failure to Notify Resident Representative of Significant Weight Loss and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal representative of significant changes in condition and treatment, as required by facility policy and state licensure regulations. The facility’s written policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there were accidents, significant changes in physical, mental, or psychosocial condition, or circumstances requiring alteration of treatment, including new treatments. Resident 3 was admitted with Alzheimer’s disease with late onset and stage 3 chronic kidney disease, and the admission record identified a family member as POA. The POA reported being told months earlier at a care conference that the resident was losing weight and would start a supplement, but reported receiving no further information about the resident’s weight loss until the resident was placed on hospice. The social service note for that care conference did not document weight loss as a concern. Weight records showed a progressive and significant weight loss over several months, with multiple documented 5–10% or greater changes from prior comparison weights. During this period, several new clinical interventions and orders were initiated in response to the resident’s condition, including starting a nutritional supplement (med pass 60 cc three times daily) for slow weight loss, potassium chloride for hypokalemia, metformin for prediabetes, and mirtazapine for dementia with depression and weight loss, as well as orders for a prealbumin lab, weekly weights, and a renal ultrasound due to a history of mass and significant weight loss. A handwritten note indicated the family declined the ultrasound. However, a review of progress notes and medical professional notes between late October and early January did not show documentation that the POA was notified of the resident’s weight changes or the new orders for potassium chloride, metformin, mirtazapine, or the prealbumin lab. The registered dietitian confirmed not speaking with the family about the weight loss, and the ADON confirmed that nurses are expected to notify the POA of changes in condition, including weight loss and medication changes, and that no additional documentation of POA notification could be found.
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