Failure to Notify Physician of Significant Ongoing Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant and ongoing weight loss and to document this change as required. The resident had diagnoses including dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of both arms, and a cognitive communication deficit. A hospital discharge document listed weight loss and malnutrition as ongoing problems, with a most recent hospital weight of 181 lbs, and the facility’s weight log on admission showed 180.6 lbs. On 12/8, the resident’s weight was documented as 160 lbs, representing an 11.41% loss from 180.6 lbs, but the admission weight was later cancelled as a data entry error by the dietician without a progress note explaining why. There was no documentation that the physician was notified of this weight change, and a physician progress note dated several days later still listed the resident’s weight as 180.6 lbs with no indication of awareness of the 160-lb weight. Subsequent weights showed continued decline: 149.3 lbs in early January, 146.4 lbs a week later, 143.9 lbs in mid-February, and 140.7 lbs in late March, amounting to approximately a 22% loss from the documented 181 lbs over about four months. Physician progress notes in January and March did not indicate that the facility had informed the physician of the resident’s significant weight loss or that the resident had been assessed for it. Nursing staff reported the resident needed cueing and encouragement to eat and that she was not being monitored for weight loss. Observations showed the resident refused one lunch without documented alternatives offered and ate less than half of another lunch. The DON stated the facility expected some weight loss after hospitalization for sepsis and fluid/diuretic use and acknowledged the facility was not following the resident for weight loss even as it continued for months, and there was no documentation that the physician had been notified and evaluated the resident for this ongoing significant weight loss, contrary to the facility’s weight management policy requiring MD and family notification.
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