Failure to Notify Physician of Change in Condition and Significant Weight Gain
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician of significant changes in condition, including symptoms related to cellulitis and a substantial weight gain. The facility’s own “Notification of Changes” policy required prompt physician consultation and notification of the resident and representative for significant physical changes, deterioration in health status, or circumstances requiring alteration of treatment. The resident had multiple serious diagnoses, including alcohol cirrhosis of the liver, anemia, end stage renal disease, depression, cellulitis, hepatic encephalopathy, morbid obesity, and heart failure. The MDS dated 2/18/26 documented that the resident’s cognition was intact, the resident reported feeling down or depressed, and had a weight of 411 pounds with a weight gain of 5% or more in the last month or 10% or more in the last six months, without being on a prescribed weight gain regimen. Nursing progress notes showed that on 11/28/25 staff documented that the resident did not look good, had loss of appetite, did not eat breakfast, and was very drowsy. Throughout that day, the resident refused lunch and dinner due to poor appetite, reported feeling tired with little energy, remained lethargic and weak, and refused hospitalization when suggested by staff. Later that evening, the resident’s oxygen saturation was documented at 88%, and there was no further documented assessment after 9:53 PM until 10:30 AM the next day, when the resident was noted to be pale with flushed cheeks and a left stump that was bright red, edematous, warm, and tender; only then was the physician notified and the resident sent to the emergency room, where the resident was admitted for cellulitis. Additionally, weight records showed an increase from 390 pounds on 2/3/26 to 412 pounds on 2/10/26 (a 22‑pound, 6% gain in one week), and then 415 pounds on 2/12/26, with no evidence that the physician was notified of this significant weight gain.
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