F0580

D

Failure to Notify Resident Representative of Significant Change in Condition and Worsening Symptoms

Crawfordsville, Indiana Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify a cognitively intact resident’s emergency contact and/or resident representative of significant changes in his condition, and failure to document any consultation with the resident or representative regarding transfer to the hospital. Resident B had diagnoses including prostate cancer, lung cancer, insulin-dependent diabetes mellitus, and GERD, but was assessed on a recent quarterly MDS as cognitively intact and independent with eating, mobility, and ambulation, with good oral intake and recent weight gain. On one day, nursing documentation showed he developed new symptoms of coughing, coffee-ground emesis, and a sensation of feeling drunk and staggering when ambulating. The physician was contacted and ordered a CBC and medication changes, including discontinuing diclofenac and starting protonix for GI upset, but the nursing notes from that day did not document any notification of the resident’s family or emergency contact.

On the following day, nursing notes documented that Resident B continued to have nausea and vomiting, confusion, dizziness, abdominal pain, and a pulse of 128. The physician ordered STAT chest and abdominal x‑rays and a STAT CBC, which was never obtained before the resident’s death. Later that same day, documentation showed the resident continued to have yellow liquid emesis, ongoing confusion, and a temperature of 99.1°F, and the physician ordered additional medications including sennosides-docusate, Miralax, and doxycycline for pleural effusion. None of these notes contained documentation that the family or emergency contact was notified of the resident’s ongoing and worsening condition or of the new treatment orders. The clinical record also lacked documentation that the resident or his representative was consulted about his preference for transfer to the ER for evaluation and treatment during this period of decline.

On the morning of his death, the DON’s progress note documented that CNAs and an LPN found Resident B with bile-like emesis in a trash can and on the bed, and that he became unresponsive with no pulse or respirations while the nurse was in the room. CPR was initiated at 4:50 a.m., EMS arrived shortly thereafter, and resuscitation efforts were stopped at 5:20 a.m., after which the resident was pronounced deceased. The daughter, ED, DON, and Regional Director of Clinical Services were notified after his death, and the coroner later took possession of the body. Confidential staff interviews indicated staff were aware the resident had been ill with vomiting, including coffee-ground emesis and altered mental status, and one staff member reported being told that upper management would not allow the resident to go to the hospital. Another staff member stated that the DON had been kept apprised of the resident’s deteriorating symptoms and had instructed staff to wait for physician orders before sending him to the hospital. The daughter reported she was the emergency contact, had frequent contact with the resident, and learned from him that he was vomiting black material, could not walk, and was confused, but she was not notified by staff of his change in condition and instead only received a call after his death. Review of the clinical record with the ED and DON confirmed there was no documentation that the emergency contact had been notified of the resident’s change in condition or that the resident’s wishes regarding ER transfer had been obtained, despite a facility policy requiring immediate notification of the resident, physician, and resident representative for significant changes in condition.