F0580

D

Failure to Notify POA, Physician, and Hospice of Resident’s Change in Condition

New Holstein, Wisconsin Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The facility failed to notify an activated Power of Attorney for Healthcare (POAHC), the physician, and Hospice services of a significant change in condition for one resident. The facility’s policy on Change in Condition of a Resident, revised 9/20/22, required immediate notification of the resident, consultation with the physician, and notification of the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status. The resident involved was receiving Hospice services and had diagnoses including heart failure, COVID-19, hypertension, diabetes, and atrial fibrillation. An MDS assessment dated 9/21/25 showed a BIMS score of 14/15, indicating intact cognition, and the activated POAHC assisted the resident with medical decisions.

On 9/25/25 at 5:22 AM, a progress note documented that the resident moaned during cares, had an increased respiratory rate, was diaphoretic, and was not talking. Vital signs at that time included a blood pressure of 130/51, respirations of 26, oxygen saturation of 85%, and blood sugar of 286. Despite these findings, the medical record contained no indication that the POAHC, physician, or Hospice services were notified of this change in condition. A Hospice note later documented that the resident died on 9/25/25 at 9:45 AM. During interviews, the POAHC stated they were not notified of the change in condition and were upset they were unable to be present when the resident died. The Director of Hospice Services, the Unit Manager, and the DON each confirmed that the 5:22 AM progress note reflected a change in condition that should have been reported to the POAHC, physician, and Hospice services at the time it was identified.