F0580

E

Failure to Notify Physician and Representative of Resident’s Poor Intake and Medication Refusals

Jefferson, Texas Survey Completed on 02-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s physician and resident representative (RP) of significant changes in the resident’s condition, including poor oral intake, refusal of meals, and refusal of medications, as required by facility policy. The resident was an older adult with multiple serious diagnoses, including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant brain neoplasm, repeated falls, depression, and hypertension. A quarterly MDS showed severe cognitive impairment (BIMS score of 7), total dependence for all ADLs including eating, wheelchair use, and complete bowel and bladder incontinence. The care plan identified a nutritional problem or risk and directed staff to monitor, document, and report to the MD as needed for signs and symptoms of dysphagia, including refusing to eat.

Record review showed an order for a health shake to be given if the resident consumed less than 50% of a meal, with instructions to encourage intake and notify the nurse. The MAR and order summary contained this order, but there was no documentation that the resident ever received a health shake during the review period. Nutrition intake records documented repeated days where the resident ate 0–25% of meals, refused entire meals, or had missing documentation for some meals over multiple days. Despite this pattern of poor intake and refusals, nurses’ notes from the beginning to the middle of the month did not show that the physician or the resident’s RP were notified about the resident’s refusal of meals or poor eating.

On one date, a medication aide documented that the resident was resistant to medication administration, swinging and swatting, not allowing blood pressure to be taken, and not swallowing anything, but there was no documentation that the nurse was notified of this behavior. In interviews, the resident’s RPs stated they had not been informed of the resident’s refusal to eat or take anything by mouth and indicated they would have intervened had they known. The physician reported he did not recall being notified that the resident was not eating well or that the resident was combative and refusing medications, and stated he would have expected notification so he could implement interventions. Facility staff, including an LVN, the DON, and the ADM, acknowledged in interviews that such changes in condition, including meal refusals, medication refusals, and abnormal behaviors, should have been reported to the nurse, the physician, and the RP, in accordance with the facility’s written policy on change in condition, which requires prompt notification of the physician and representative for significant changes and for refusal of treatment or medications three or more consecutive times.

The facility’s policy titled "Change in a Resident's Condition or Status" required the nurse to notify the attending or on-call physician when there was a significant change in the resident’s physical, emotional, or mental condition, and when there was refusal of treatment or medications three or more consecutive times. It also required notification of the resident’s representative when there was a significant change in the resident’s physical, mental, or psychosocial status, with notifications to be made within 24 hours of the change, except in emergencies. Despite these requirements, the record and interview evidence showed that the physician and RPs were not notified of the resident’s ongoing poor oral intake, repeated meal refusals, and the episode of combative behavior and medication refusal, leading to the cited deficiency for failure to promptly notify the physician and resident representative of changes in condition.