Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative after a significant change in condition, specifically a significant weight loss. The facility’s policy on Notification of Change in Condition requires informing the resident, consulting with the resident’s medical practitioner, and/or notifying the resident’s representative or authorized family member when there is a significant change in the resident’s physical, mental, or psychosocial condition, including deterioration in health or clinical complications. During a complaint survey, it was determined that this policy was not followed for one resident. The complaint alleged that this resident was not provided with quality of care, prompting review of administrative documents, a closed medical record, and staff interviews. The resident involved had multiple diagnoses, including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, prior stroke with left-sided weakness, polyneuropathy, anemia in chronic kidney disease, hyperlipidemia, dementia, Vitamin D deficiency, GERD, and arthritis due to Lyme disease. A BIMS score obtained earlier showed severe cognitive impairment (6/15). Review of the resident’s record showed a weight of 199.3 pounds in early December and 183.0–183.5 pounds in early January, representing a 7.9% (15.8-pound) weight loss in one month. The facility dietician stated that the electronic medical charting system generates alerts to department managers for significant changes in condition, and that significant weight loss is an alert item. The resident’s significant weight loss was identified and confirmed, but another staff member cleared the weight loss alert, and as a result, department managers and the resident’s physician were not immediately made aware of the significant change in condition, constituting the cited deficiency.
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