•
On
admission 08/22/01 resident’s
height was 68 inches and weight was 143. At the acute care hospital
his
height was listed as 72.4 inches and weight 153 pounds. This
discrepancy was never brought to the
physician’s
attention. •
Significant
weight losses and gains not called to the
physician. On 10/03/01 –10 lbs
MD
not
notified. On 10/10/01 weekly weight
gain of +3 lbs. Not
called to MD. On 10/17/01 weekly weight
loss of -3 lbs.
Not
called to MD. On 11/24/01 monthly weight
gain of +7 lbs not
called to MD. On 05/24/02 monthly weight
loss of –6 ¾ lbs not
called to MD. Malnutrition and weight loss
should
have been monitored
very closely. •
On
10/25/01 nurse’s
documented
“coughing and unable to swallow breakfast, has congestion, suctioned
and kept comfortable” physician
was not notified
of increased coughing which required suctioning. An MD
order
for
suctioning
PRN/excessive secretions
should
have been obtained. No assessment
of lung sounds
documented. Resident
has history
of chronic aspirations and pneumonias,
which increases
risk for dehydration. •
On
01/23/02 Mr.
Patient
was noted coughing
up milky colored phlegm
and some coming
out of his nose. Noted with
rhonchi. Dr.
Doctor
paged and message left for him at the office. No documentation if
physician
ever called back.
Mr.
Patient
has history
of chronic aspiration.
Markup
Color Codes: Anaphoric
reference Operational
Discrepancy Nonsyntactic
Phrase Patient
Condition Alert Lexical
Dialect Failure
to Notify MD of Change of
Condition Fragment
of Actual Medical
Record
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