Failure to Notify Representatives and Physicians of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly inform resident representatives and physicians of significant changes in condition, specifically substantial weight loss, for two residents. Resident #1 had multiple diagnoses including dementia with mood disturbance, bilateral knee pain, vitamin B and D deficiencies, essential hypertension, anemia, type 2 diabetes mellitus without complications, hyperlipidemia, and hypothyroidism. Weight records showed a decline from 106.2 pounds on 10/6/2025 to 93.2 pounds on 3/2/2026, a 12.24% weight loss. Review of nursing progress notes from October 1, 2025 through March 2, 2026 revealed no documentation that the resident’s representative or physician was notified of this change in condition. The resident’s representative reported not being informed of the weight loss, any interventions, or dietician involvement, and an LPN acknowledged that the physician and representative had not been contacted or that such communication had been documented. Resident #2 had diagnoses including cerebral infarction, peripheral vascular disease, history of falling, hyperlipidemia, essential primary hypertension, unspecified systolic congestive heart failure, urinary retention, pseudobulbar effect, vitamin D deficiency, major depressive disorder, primary insomnia, bipolar disorder, benign prostatic hyperplasia, atherosclerosis of other arteries, idiopathic peripheral autonomic neuropathy, vascular dementia, and mild protein calorie malnutrition. Weight records showed a decline from 185.4 pounds on 10/3/2025 to 163.1 pounds on 3/3/2026, a 12.3% weight loss over six months. The Registered Dietician stated that notifying families and physicians about weight loss was the responsibility of nursing staff. The DON confirmed there was no documentation of family or physician notification for these significant weight losses, despite a facility policy titled “Change in Condition Process” requiring prompt notification of the resident, physician, and representative when there is a change requiring such notification, including changes necessitating significant alteration of treatment and completion of an SBER Change in Condition evaluation in the electronic medical record.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.