Failure to Notify Physician of Significant Weight Gain in Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician of a significant weight change for one resident, as required by its own Nursing Standards of Practice and Documentation policy dated 10/2024. That policy states that on the day weights are obtained, the primary nurse will compare the admission weight to the current weight and determine if criteria have been met to notify the attending physician and dietician, and that the attending physician will be notified of a weight change from time of admission of plus or minus 10%. Review of the resident’s electronic medical record showed an admission weight of 138 pounds on 12/12/2025, a weight of 147 pounds on 12/15/2025, and a weight of 154 pounds on 12/16/2026, representing an 11.6% weight gain since admission, which met the facility’s threshold for mandatory physician notification. The resident had diagnoses including congestive heart failure, end stage renal disease, and was receiving hemodialysis. Despite the documented weight gain exceeding the 10% notification criterion, interviews with two registered nurses (S5 and S6) revealed that neither reported the weight gain to the nurse practitioner or physician. Further interviews confirmed that the resident’s nurse practitioner and nephrologist were not notified of the weight change. The nurse practitioner stated that, had he been informed, he would have notified the nephrologist. The Director of Nursing acknowledged that the resident’s weight gain should have been reported to the nurse practitioner or doctor and was not, as required by facility policy.
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