Failure to Notify Physician of Significant Change in Resident's Condition
Summary
The facility failed to implement its policy and procedure regarding the notification of a physician for a significant change in a resident's condition. Specifically, the facility did not ensure that the physician was immediately notified when a resident experienced a significant change in vital signs, including decreased blood pressure and increased heart rate, as well as new pain, moaning, fidgeting, and agitation. The Licensed Vocational Nurse (LVN) did not notify the Registered Nurse (RN) or the physician about these changes, which were significant deviations from the resident's baseline condition. The resident, who had a history of severe cognitive impairment and required assistance with daily activities, was found with a blood pressure and heart rate that indicated a significant change from their baseline. Despite these changes, there was no documented evidence that the physician was notified. Additionally, the resident was observed to be in pain, with a pain level of 7 out of 10, but the physician was not informed, and no stronger pain medication was administered beyond Tylenol. The resident's condition continued to deteriorate, leading to unresponsiveness and eventually death. The facility's failure to notify the physician and conduct appropriate assessments and interventions resulted in the resident not receiving the necessary care to address the significant changes in their condition. The lack of timely notification and documentation of the resident's condition changes contributed to the resident's continued decline and eventual death, as the facility did not adhere to its policies for managing changes in a resident's condition.
Removal Plan
- Current licensed nurses were re-in serviced in person regarding identifying abnormal vital signs and documentation for a change of condition, including changes in pain level, respiratory status, oxygen saturation rate, and out of range blood pressure. The DSD/Designee will in-service licensed staff in person to complete 100% in-service to licensed staff.
- Current licensed nurses were re-in serviced in person on timely notification of a RN or the Director of Nursing (DON) regarding a change of condition, including changes in vital signs. The DSD/Designee will in-service license staff in person to complete 100% in-service licensed staff.
- A follow up in-service will be conducted to determine knowledge retention for timely notification of a RN and physician regarding a change of condition.
- Licensed nurses will be assessed for documentation competency, including notification of RN and physician for a change in condition, using the Documentation Competency Checklist. Competencies for all licensed staff will be completed within 30 days from initiation of Documentation Competency Checklist, 90 days after first licensed staff evaluation, and then annually thereafter.
- Licensed nurses will be in-serviced in person by DON/DSD/Designee regarding new Documentation Competency Checklist. DON/DSD/Designee will in-service license staff in person to complete a 100% in-service to license staff.
- Competency Checklist will be added to all new hire LVN/RN orientation.
- Policy and Procedure will be updated to reflect new audit tool, including elements to be incorporated into the audit such a documentation of changes in condition notification of RN and physician, and completion of appropriate assessments.
- Policy and Procedure will be updated to reflect procedure for documentation of change in condition, including parameters for notifying RN or physician.
- DSD/Designee will complete random audits to test knowledge of in-service regarding notification of changes to RN and physician. Results will be logged on the spot check tool. Audits will be complete 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months.
- LVN 1 will be provided an additional 1:1 in-service on proper notification of a physician and the RN for any changes in condition.
- LVN 1 will meet with the DON/Designee on a regular basis to review any changes in condition during the scheduled shift for the next 30 scheduled workdays. 1:1 in-service will be provided as needed.
- Certified Nursing Assistants (CNAs) were re-in-serviced regarding reporting of changes in condition to the supervisor or charge nurse.
- A follow up in-service will be conducted to determine knowledge retention for reporting of changes in condition.
- Residents with any changes in condition will be reviewed in morning meeting by the IDT. Any findings on the audit tool (Exhibit 1.1) will be addressed, 1:1 in-service will be provided as needed.
- Review of documentation of changes in condition, including notification of RN and physician, will be completed at various times weekly by DON/Designee for the next 30 days then semi-monthly for 1 month then monthly for 1 month. Issues noted will be resolved. 1:1 in-service will be provided as needed. Information for which charts to review will be based on the audit tool (Exhibit 1.1).
- Consultant will review a random sampling of resident charts, based on audit tool (Exhibit 1.1) on a regular basis for 30 days or CDPH revisit, whichever is longer, to verify that documentation has been completed for patients with any changes in condition, including notification to RN and physician. Issues noted will be resolved and additional in-services will be provided as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
A resident with severe cognitive impairment and a history of falls, weakness, malnutrition, and difficulty walking was found on the floor and later developed persistent right hip, thigh, and RLE pain with inability to bear weight. PT and OT notes documented worsening pain and limited mobility, but progress notes did not show notification to the MD or NP. The resident was later sent to the hospital, where imaging showed a displaced right femoral neck fracture.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
A resident had an unwitnessed fall, but the physician and resident representative were not notified until the next morning. The facility’s policy required prompt assessment and notification after a fall, and the resident had capacity to understand and make decisions. An LVN said the delay occurred because the resident did not show a change in condition, while an RN stated the nurse should have notified the physician and representative immediately after assessing the resident.
A facility failed to notify family representatives about missed morning medications for eight residents. MARs showed blank administration entries for the medication pass, and Progress Notes did not document family notification. Interviews with family members and the POA confirmed they were not told about the medication omissions, while the DON stated notifying families of medication errors is standard practice and should be documented.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Notify Provider of New Right Hip Pain and Inability to Bear Weight
Penalty
Summary
The facility failed to follow its policy for notification of a change in resident condition by not notifying the physician and/or nurse practitioner when a resident developed new right lower extremity pain and inability to bear weight. The resident had a history that included weakness, unspecified fall, hypotension, severe protein calorie malnutrition, major depressive disorder, cognitive communication deficit, metabolic encephalopathy, and difficulty walking, and had a BIMS score of 4/15 indicating severe impairment. After the resident was found on the floor on the right side next to the bed with lacerations, redness to both knees, a laceration to the right ankle, and redness to the right hip, the resident initially denied pain. Subsequent PT and OT documentation repeatedly recorded pain in the right hip, thigh, and right lower extremity, with pain increasing with movement, sitting, standing, bending, and weight bearing. PT notes documented that the resident required walker support, took only a few small steps with max assist due to pain, later became unable to ambulate because of severe right lower extremity pain, and was unable to put weight on the leg and had difficulty standing. OT notes also documented aching right lower extremity pain that limited lower body ADLs and functional mobility tasks. The progress notes did not document notification to the doctor or nurse practitioner about the pain or the changes in the resident's right lower extremity. When the resident was later sent to the hospital at the family’s request, the nurse practitioner and ADON were made aware, and the resident was transported by ambulance. The hospital record documented right hip pain, tenderness to palpation and with range of motion of the right hip, and x-ray findings of a superolateral displaced right femoral neck fracture. The hospital history noted the resident may have fallen two weeks earlier, and the daughter reported the last time she saw the resident walking was four weeks earlier. Staff interviews indicated the APRN and NP were not notified of the pain or inability to bear weight, and both stated they would have assessed the resident and likely ordered an x-ray if they had been informed.
Failure to Notify Legal Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident's legal representative of a significant change in condition for one resident reviewed for notification of changes. The resident was admitted with pneumonitis due to inhalation of food and vomit, dysphagia, and stage 3 chronic kidney disease. The Minimum Data Set dated 05/06/2026 documented that the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. On 05/14/2026, the resident experienced a vasovagal episode while in the shower and later had episodes of vomiting, including brown-colored emesis. Progress notes documented that staff notified the PA of the resident's condition, assessed the resident, and monitored vital signs. The facility policy titled Notification Policy required the attending physician or designee and the resident or resident's legal representative or interested family member to be notified by the nurse of a significant change in condition, including vomiting, change in mentation, change in vital signs, or respiratory distress. There was no documented evidence that Family Member #2 was immediately notified of the vasovagal episode or the vomiting. Family Member #2 stated they were not informed of these events and first learned from the facility when told the resident had passed away at 12:07 PM. Staff interviews confirmed that family notification was expected for significant changes, and the PA stated they were contacted about the vasovagal episode, the vomiting, and later the resident's death.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Delayed Notification After Resident Fall
Penalty
Summary
The facility failed to notify Resident 4’s physician and resident representative of an unwitnessed fall in a timely manner. The facility’s Fall Prevention and Response policy stated that after a fall, a licensed nurse shall promptly respond, assess the resident, and notify the physician and resident representative. Resident 4 was admitted to the facility and had an H&P showing the resident had the capacity to understand and make decisions. Resident 4’s SBAR Fall Report documented a fall on 5/3/26 at 2330 hours, but the physician and resident representative were not notified until 5/4/26 at 0744 hours. LVN 1 stated the resident was monitored closely after the fall and that notification was delayed until the following morning because the resident did not exhibit a change in condition. RN 1 verified the fall occurred and stated the licensed nurse should notify the physician and resident representative immediately after assessing the resident rather than waiting until the next morning. The DON was informed and acknowledged the findings.
Failure to Notify Families of Missed Morning Medications
Penalty
Summary
The facility failed to notify resident family representatives of missed administration of significant morning medications for eight residents. Review of the Medication Administration Records for R1, R2, R3, R4, R5, R6, R7, and R8 showed blank boxes without nurses’ initials to indicate the medications were administered on 5/10/26 during morning medication pass. The residents’ Progress Notes did not document that family representatives were notified of the medication omission errors. Interviews confirmed the lack of notification. On 5/21/26, R8’s POA stated the facility did not notify her that R8 missed medications on Mother’s Day. On the same day, R1’s family member stated she was not contacted about the missed medications, and R2’s family member stated no one called or told him there were problems with his father receiving medications. The Interim DON stated it is standard practice for family representatives to be notified of medication errors, that floor nurses are expected to contact families, and that the notification should be documented in the resident’s medical record. The facility policy on Physician-Family Notification-Change in Condition states the facility will inform the resident, consult the physician or authorized designee, and if known, notify the legal representative or interested family member.
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