F0580

D

Failure to Notify Provider of Significant Change in Resident Condition

Grantsburg, Wisconsin Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the provider of a significant change in condition for one resident. The resident was admitted with atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. A Plan of Care note documented that around 3:00 AM the resident experienced weakness and confusion, with difficulty walking observed by a CNA. The nurse’s assessment noted labored, puffing respirations, the resident feeling scared but denying pain, a flaccid left arm, unequal and very weak left hand grasp with notable swelling, incorrect responses to orientation questions except for name, and no facial droop with pupils equal and reactive. The resident was assisted via wheelchair to the bathroom and back to bed and was able to swallow water without difficulty.

The same Plan of Care note documented that a call was placed to a family member, who agreed with the resident remaining in bed at the facility rather than going to the ER. However, there was no documentation that the provider was notified of this significant change in condition. The Interim DON confirmed in interview that the provider should have been notified as soon as possible. A former DON (now RN) stated that any change in condition should prompt a call to the physician, that she did not recall receiving any call about this event, and that staff should not have called the family and taken direction from them first. Review of the facility’s policy “Change in a Resident’s Condition or Status” stated that the nurse will notify the attending physician or provider when there is a significant change in the resident’s physical, emotional, or cognitive condition or a need to significantly alter medical treatment, which did not occur in this case.