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.
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