Failure to Notify On-Call Provider and Medication Error Leads to Resident's Death
Summary
The facility failed to immediately consult with the on-call Nurse Practitioner when a resident experienced a significant change in condition. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and respiratory failure, showed signs of restlessness, agitation, and expressed difficulty breathing. Despite these symptoms, the staff did not notify the on-call provider, and the resident was later found unresponsive with seriously abnormal vital signs. Interviews with staff revealed that the resident was anxious, restless, and repeatedly expressed difficulty breathing throughout the night. Multiple nurse aides reported the resident's condition to the nurses on duty, but the nurses did not take appropriate action. One nurse assumed that the resident's condition was baseline and did not notify the physician, while another nurse administered Ativan, a medication to which the resident had a documented allergy. The resident's condition deteriorated, and she was found unresponsive with low oxygen saturation levels. Emergency Medical Services were called, but the resident was pronounced deceased shortly after their arrival. The facility's failure to notify the on-call provider and administer a medication despite a known allergy contributed to the resident's death.
Removal Plan
- The facility failed to notify the on-call medical provider that Resident #1 had experienced a change of condition.
- An audit was completed by the Director of Nursing and designee to review nursing notes to ensure any noted changes in residents' condition were noted and the physician had been notified.
- Education started by the Director of Nursing for the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues.
- Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education.
- New licensed nurses and medication aides will receive education during the orientation process.
- Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift.
- Director of nursing reeducated all certified nursing assistants on verbally reporting any noted change in condition such as altered mental status, abnormal behaviors, abnormal vital signs, etc. to the nurse for assessment.
- All nursing note reviews, and reports reviews were completed by the Director of Nursing or designee to ensure noted changes in condition were addressed, vitals taken and physician notified.
- Nursing note reviews will be completed by the Director of Nursing or Designee on residents.
- New changes in conditions will be reviewed by the nursing clinical team during clinical meetings for any noted change in condition and physician notification.
- New changes in condition from the weekend will be reviewed by the nursing clinical team during the clinical meeting.
- The nursing team was notified of this responsibility by the facility administrator.
- The results of the monitoring will be reviewed by the Administrator or Director of Nursing in the Risk meeting and during the Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT).
- Changes will be made to the plan as necessary to maintain compliance with resident safety.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with diabetes, hypertension, and dementia had physician orders for Accu-Chek blood glucose monitoring four times daily, with instructions to notify the provider for readings below 90 or above 350. The care plan required staff to obtain blood sugars as ordered and notify the physician of abnormal results. Review of the MAR showed multiple low and high blood sugar values documented as abnormal, yet marked with "N" indicating no physician notification. An LPN confirmed that an "N" entry meant the physician was not notified, and the Executive Director could not locate documentation of any notifications for these abnormal readings and acknowledged there was no facility policy for call orders and physician notification.
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Licensed nurses failed to notify a resident’s representative of two significant changes in condition: an elopement and a subsequent fever. The resident had severe cognitive impairment, was deemed unable to make his own health decisions, and had a Wanderguard order for exit-seeking behavior. After the resident left the building and was returned by police, there was no documentation that the representative was informed. Later, when the resident developed a fever with respiratory symptoms and the MD was notified and treatment given, there was again no documentation of representative notification. The DON confirmed expectations and facility policies required notifying the resident’s representative and documenting these contacts, and one nurse admitted she did not know she had to report the fever.
A resident with complex cardiopulmonary conditions had a critical CO2 lab value reported to an LVN, who documented that the NP and DON were informed but did not complete a change-of-condition assessment, did not document vital signs, and did not document any notification to the resident or the resident’s representative. Another LVN later phoned the NP about the critical lab but failed to document that contact. The DON and NP reported that the first LVN used unsecured text/email instead of required phone calls and did not follow established change-of-condition and notification protocols. The resident and the resident’s emergency contact stated they were never told about the abnormal lab result, leading to a deficiency for failure to promptly inform the resident, consult with the practitioner, and notify the resident’s representative of a significant change in condition.
Failure to Notify Physician of Abnormal Blood Glucose Readings
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of abnormal blood glucose readings as ordered for a resident with type 2 diabetes mellitus, hypertension, and dementia. The resident’s care plan, dated 4/2/25, identified risk for complications and symptoms of hypoglycemia and hyperglycemia and included an intervention to obtain blood sugars as ordered and to document and notify the physician of abnormal findings. A physician’s order, dated 4/3/25 and discontinued 4/2/26, directed staff to obtain Accu-Chek blood sugar readings four times daily and to notify the provider if the blood sugar was less than 90 or greater than 350. Review of the Medication Administration Record showed multiple abnormal blood sugar readings during the ordered period that were marked with “N” for no physician notification, including low readings of 85, 74, 80, 83, 82, and 84, and high readings of 368 and 367. Interviews revealed that when “N” was documented on the MAR, the physician would not have been notified, and the Executive Director was unable to find documentation of physician notification for the low blood sugar readings. The Executive Director also stated that if the physician had been in the building at the time of an abnormal reading, the nurse would have notified the physician and documented it in a progress note, but no such documentation was found. Additionally, the Executive Director reported that the facility did not have a policy regarding call orders and physician notification.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Notify Resident Representative of Elopement and Fever
Penalty
Summary
Licensed nurses failed to notify a resident’s responsible party (RP) of significant changes in condition and status, including an elopement and a fever. The resident had dementia, bipolar disorder, a cognitive communication deficit, repeated falls, and an active order stating he was not capable of making his own health decisions, with his daughter listed as the RP and emergency contact. He also had an active order for a Wanderguard due to exit-seeking behavior. On 2/28/26, a change of condition note documented that the resident eloped from the facility sometime after he was last seen in bed at 4:00 a.m. and was found by police at a baseball field across from the facility and returned around 5:00 a.m. The note also indicated the Wanderguard was in place but did not alarm when the resident exited. There was no documentation that the RP was notified of this elopement. On 3/1/26, a progress note documented by a licensed nurse indicated a change of condition for fever, with the resident noted to be sneezing and congested, and temperatures of 100.4°F and later 101.1°F recorded, with acetaminophen administered and the MD notified for congestion medicine. There was no documented evidence that the RP was notified of the fever. In an interview, the RP stated she was not informed by the facility of the elopement and learned of it from a friend who heard the resident’s name on a dispatch call, and she later observed new coughing when visiting the resident. The DON stated she expected licensed nurses to complete change of condition reports for elopement and fever and to notify the RP, and confirmed there was no documentation of such notifications. One licensed nurse acknowledged she did not notify the RP of the fever because she did not know it was required. Facility policies on wandering/elopement and change in condition required notification of the resident’s legal representative or resident representative and documentation in the medical record when such events occurred.
Failure to Notify Resident, Practitioner, and Representative of Critical CO2 Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident, the resident’s practitioner, and the resident’s representative of a significant change in condition related to a critical laboratory result. The resident was admitted with multiple serious cardiopulmonary diagnoses, including heart failure, obstructive sleep apnea, chronic pulmonary edema, and acute and chronic respiratory failure with hypoxia. Her admission MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and her care plan included monitoring for altered respiratory status and reporting signs and symptoms of respiratory distress to the physician as needed. A lab report dated 3/2/26 showed a critical CO2 value of 42 (reference range 21–31), flagged as a critical result, and documentation showed that LVN A was notified of this critical lab in the evening. In response to the critical lab, LVN A entered a progress note in the early morning hours stating that the resident had a critical CO2 result of 42, that the NP and DON were informed, and that the resident was stable at that time. However, there was no further documentation by LVN A describing a change of condition assessment, vital signs, or notification of the resident or her representative, and no change of condition assessment was found in the March assessments in response to the critical CO2 value. The DON later stated that LVN A had notified the NP and DON via text message rather than by phone, and that LVN A should have called the NP and DON for a critical lab, which was considered a change of condition, and should have contacted the on‑call nurse if unable to reach them. The NP reported that LVN A often did not follow protocols and that he texted her about the critical lab via his personal email, which she stated was not secure and violated HIPAA. On the following morning, LVN B documented that the night nurse had sent the results to the NP and was awaiting a response, and LVN B then called the NP to inform her of the critical CO2 value and the resident’s assessment. LVN B did not enter a progress note at that time and later stated she must have forgotten to document the call. When interviewed, the resident and her emergency contact both stated that facility staff had not notified them of any abnormal lab results, and the resident expressed that no one had talked to her about the abnormal lab and that she would have wanted the opportunity to decide whether to go to the hospital. Facility policy on change of condition required prompt notification of the attending physician and the resident or responsible party for significant changes, including serious abnormal labs, and required documentation of the time and method of physician contact and family notification. The survey findings showed that these notification and documentation requirements were not followed for this resident’s critical CO2 lab result. The facility’s own policy defined an acute change of condition as a clinically important deviation from baseline that, without intervention, may result in complications or death, and specified that serious abnormal labs required immediate physician notification, notification of nursing supervision, and prompt notification of the resident and responsible party. Interviews with LVN A confirmed his understanding that a critical lab was considered a change of condition, that he was required to assess the resident, obtain vitals, notify the NP and DON by phone, notify the resident’s representative, and document these actions, and that texting was not sufficient. Despite this, he could not recall what he did in response to this specific critical lab beyond the brief progress note, and there was no documentation that the resident or her emergency contact were informed. These actions and omissions led to the cited deficiency for failure to immediately inform the resident, consult with the physician, and notify the resident representative of a significant change in condition. The NP stated that when she was later contacted by LVN B, she understood the resident’s chronic hypercarbic respiratory failure and elevated CO2 levels and discussed that the resident was on oxygen and needed to be off due to CO2 retention. She noted that the resident was not in distress when assessed by LVN B and during her own rounding. However, the survey focused on the lack of timely, appropriate notification and documentation at the time the critical lab was first reported to LVN A, and on the resident and emergency contact’s report that they were not informed of the abnormal lab result. The combination of failure to follow the facility’s change of condition policy, failure to use appropriate communication methods with the NP and DON, failure to notify the resident and her representative, and incomplete documentation formed the basis of the deficiency.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
