Failure to Notify Provider of Significant Weight Loss
Summary
The facility failed to notify the provider of a significant weight loss for one of the residents, identified as Resident #89, who was at risk for nutritional deficit due to diuretic use. The resident's care plan required monitoring of weights and notifying the dietician, family, and physician of significant weight changes. A physician's order specified that the resident should be weighed daily and the provider notified of a weight change of 3 pounds daily or 5 pounds weekly. However, the clinical record review showed that the resident experienced a weight loss of 9.2 pounds over five days, and there was no documentation indicating that the provider had been notified of this change. Interviews with the Unit Nurse Manager and an Advanced Practice Registered Nurse revealed that the physician was not informed of the resident's weight loss, which was a requirement according to the physician's order. The Unit Nurse Manager could not explain the omission, while the Advanced Practice Registered Nurse indicated that notification would have allowed for potential adjustments to the resident's diuretic medication. The facility's policy mandates that significant weight changes should be verified for accuracy, documented, and communicated to the resident, family, and interdisciplinary team, which was not adhered to in this case.
Penalty
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Staff failed to notify the physician and responsible party when a resident did not receive ordered doses of Metoprolol Succinate ER for heart failure and Bumetanide as a diuretic because the medications were not available from the pharmacy. The MAR showed missed morning doses marked as "Other/See Progress Note," and the progress notes indicated the facility was awaiting pharmacy supply. An LPN and the DON stated that nurses are expected to check the backup pharmacy system, contact the pharmacy, and then notify the physician and responsible party when medications are unavailable, but there was no documentation that such notifications occurred, and the facility reported having no policy governing this notification process.
Facility staff failed to notify a resident’s responsible party after the resident, who had severe cognitive impairment and multiple neurologic and respiratory diagnoses, was found on the floor with a bruised orbital area and later sent to the ER. The resident’s face sheet listed a family member as the responsible party and primary emergency contact, and facility policy required responsible party notification for significant changes of condition. Review of clinical records and interviews with leadership, including the DON, showed no documentation or evidence that the responsible party was informed of either the fall or the hospital transfer.
Two residents were affected when staff failed to provide required notifications of changes in condition and room assignments. One resident with multiple comorbidities and moderate cognitive impairment repeatedly reported feeling ill and awaiting test results for suspected flu and UTI, while documentation later showed negative COVID/flu results and a yeast infection diagnosis that were not promptly communicated to the resident, despite orders for multiple labs and provider involvement. Another resident with severe cognitive impairment and Alzheimer's disease experienced five separate room changes documented in the clinical census, and the DON and Administrator acknowledged that the resident's representative was not notified prior to these moves, contrary to facility expectations.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, which was documented by nursing staff but not reported to a physician or provider for several days. No treatment orders or dressing changes were initiated until the wound NP assessed the wound, despite facility policy requiring prompt notification and intervention. Interviews with LPNs and the DON confirmed that the expected notifications and care orders were not completed in a timely manner.
Facility staff did not notify the provider or resident representative when two residents experienced multiple episodes of blood glucose readings above 400 mg/dL, despite physician orders and facility policy requiring such notifications. Nursing staff confirmed awareness of the requirement, but clinical records lacked evidence of any notifications following these critical events.
A resident with multiple chronic conditions and a history of falls was found on the bathroom floor with injuries and significant pain. Although the physician was notified promptly and x-rays were ordered, staff interviews and documentation confirmed that the resident's representative was not informed of the incident until several hours later. The delay in notification was acknowledged by staff, who cited competing priorities, and the family expressed concern about not being notified sooner.
Failure to Notify Physician and Responsible Party When Cardiac and Diuretic Medications Were Unavailable
Penalty
Summary
Facility staff failed to notify the physician and responsible party when ordered medications were not available and therefore not administered to a resident. For Resident #24, a physician order dated 1/21/2026 directed administration of Metoprolol Succinate ER 25 mg by mouth once daily for heart failure. The January 2026 MAR reflected this order, and on 1/21/2026 at the 9:00 a.m. dose, the nurse documented a "9," indicating "Other/See Progress Note." The corresponding progress note at 11:53 a.m. on 1/21/2026 stated "Awaiting pharmacy supply," indicating the medication was not available for administration. Resident #24 also had a physician order dated 1/17/2026 for Bumetanide 0.5 mg by mouth once daily as a diuretic, which was likewise documented on the January 2026 MAR. On 1/21/2026 for the 9:00 a.m. dose, a "9" was again documented, with the progress note at 11:53 a.m. stating "Awaiting pharmacy supply." Interviews with an LPN and the DON confirmed that when a medication is not in the cart and not in the backup pharmacy system, the nurse is expected to contact the pharmacy, notify the physician and responsible party that the medication is not available, and document this in the medical record. The facility reported having no policy on notification of the physician or responsible party, and the record contained no documentation that the physician or responsible party were notified when these medications were not administered due to lack of pharmacy supply.
Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident’s change in condition following a fall and subsequent transfer to the emergency room. The resident had diagnoses including vascular dementia, stridor, cerebral infarction, and dysphagia, and an admission MDS with a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making. The resident’s face sheet identified a family member as the responsible party and primary emergency contact. Nursing documentation showed that in the early morning hours the resident was found on the floor in his room with a small bruise to the orbital area, and later that same day the resident was sent to the ER. During clinical record review, the surveyor was unable to locate any documentation that the responsible party had been notified of either the fall or the ER transfer. When requested during an end-of-day meeting, facility leadership could not provide evidence of such notification, despite a facility policy titled “Significant Change of Condition” stating that the responsible party will be notified of a change of condition. The DON later confirmed they were unable to find any notification to the responsible party regarding the fall and acknowledged that the responsible party should have been notified when the resident fell and was stabilized.
Failure to Notify Residents and Representatives of Test Results and Room Changes
Penalty
Summary
Facility staff failed to promptly notify a cognitively impaired resident of diagnostic test results related to ongoing symptoms. The resident, who had diabetes, atrial fibrillation, and renal insufficiency, reported on multiple occasions that she felt unwell, with nausea, lack of appetite, and suspected flu and UTI, and stated she was awaiting test results. Orders dated 1/19/26 included in-house COVID and flu tests, CBC, BMP, urinalysis, and urine culture and sensitivity. On 1/20/26, 1/22/26, and 1/23/26, the resident continued to report feeling ill and not having been informed of her test results or what could be done for her symptoms. An LPN later confirmed she had not been informed of any test results and needed to consult the unit manager to determine whether tests were completed and what the results were. Documentation showed a late entry nurses' note entered on 1/23/26 for 1/19/26, stating that the resident had been assessed per provider order for COVID-19 and influenza swabs, that results were negative, and that the provider was notified of the negative results. The NP stated it was the responsibility of direct care nurses, not the NP, to notify the resident or representative of test results. The NP also stated she added an addendum to her 1/19/26 progress note on 1/23/26 to document that the nurse had notified her of the test results on 1/19/26. The resident later reported that, after the 1/23/26 conversation, a nurse informed her that she had a yeast infection, would be started on medication, and that she did not have COVID-19 or the flu, indicating a delay in communicating test findings and diagnosis to the resident. Facility staff also failed to notify a resident representative of multiple room changes for a severely cognitively impaired resident with Alzheimer's disease and prostate cancer. The DON reported that this resident had five room changes and that the resident representative was not notified of any of them. Clinical census documentation confirmed room changes on five separate occasions, with moves between different units and room numbers. During a final interview, the Administrator stated that a resident or resident representative needs to be notified prior to a room change, confirming that required notification did not occur in these instances.
Failure to Notify Physician and Initiate Treatment Orders for Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the physician or provider regarding an unstageable pressure ulcer identified on a resident upon admission. The resident, who had multiple diagnoses including congestive heart failure, diabetes, and a history of pressure ulcers, was assessed with an unstageable pressure ulcer on the right hip during the admission nursing assessment. Despite documentation of the wound in daily skilled notes and skin assessments, there was no evidence of any treatment orders or dressing changes for the wound until several days later. Clinical record review showed that the pressure ulcer was present and documented, but no notification was made to the physician or provider, and no treatment orders were initiated until the wound nurse practitioner assessed the wound days after admission. Interviews with LPNs and the wound NP confirmed that standard practice required contacting the in-house or on-call provider for treatment orders when a pressure ulcer was identified, but this was not done. The director of nursing also confirmed that there were no documented treatments or dressing changes for the pressure ulcer until the wound NP's assessment. Facility policies required prompt notification of the physician or practitioner for changes in a resident's condition, including new or existing pressure ulcers, and for staff to report changes in skin integrity. Despite these policies, the required notifications and treatment orders were not obtained in a timely manner, resulting in a delay in care for the resident's pressure ulcer.
Failure to Notify Provider and Representative of Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the provider and resident representative (RR) of significant changes in condition for two residents with diabetes, as required by physician orders and facility policy. For one resident, multiple blood glucose readings exceeding 400 mg/dL were documented in the medication administration records (MARs) over several dates, but there was no evidence in the clinical record that either the provider or RR was notified of these critical results. The provider's order specifically instructed staff to call the medical doctor if blood sugar exceeded 400, yet this was not done. Interviews with nursing staff confirmed that it is standard practice and expectation to notify the provider and RR when blood sugar readings surpass dangerous thresholds, as indicated in the orders. Staff acknowledged that such instructions are routine and must be followed, emphasizing that 'an order is an order.' Despite this, review of the clinical records for both residents showed no documentation of required notifications following high blood sugar readings. The facility's policy on resident change in condition states that the licensed nurse must recognize and intervene in the event of a change, and notify the physician/provider and family/responsible party as soon as the change is identified and the resident is stable. However, in both cases, there was a lack of evidence that these notifications occurred, despite repeated instances of blood sugar levels exceeding the specified threshold.
Delayed Notification to Resident Representative After Significant Fall
Penalty
Summary
Facility staff failed to immediately notify the resident representative of a significant change in condition following a fall involving a resident with multiple complex diagnoses, including chronic atrial fibrillation, COPD, Alzheimer's disease, and a history of repeated falls and fractures. The resident, who had moderate cognitive impairment and required substantial assistance with mobility and hygiene, was found by a CNA lying on the bathroom floor without nonskid footwear, having sustained multiple skin tears, discoloration to the cheek, and complaining of left arm and elbow pain. The incident occurred in the morning, and the physician was notified promptly, with x-rays ordered for the affected areas. Despite the resident's evident pain and the presence of substantial injury, documentation and staff interviews revealed that the resident representative was not notified of the fall until several hours later, around midday. Multiple staff members, including the CNA, DOR, and LPN, confirmed that the notification to the family did not occur immediately, with the LPN stating that the delay was due to prioritizing patient care and other pressing issues. The resident's sister was present in the facility later that day and expressed concern about the delay in notification, though ultimately did not file a grievance. The facility's documentation, including the Fall Investigation Form and Change in Condition document, corroborated the timeline of the fall and the delayed notification to the resident representative. Staff interviews consistently indicated that the family was not informed until after lunch, despite the resident's significant pain and the need for medical intervention. The deficiency centers on the failure to promptly communicate a significant change in the resident's condition to the designated representative as required.
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