F0580

D

Failure to Notify Medical POA of New Physician Order and Care Plan Change

Nebraska City, Nebraska Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s activated medical power of attorney (POA) of a new physician order and change in the plan of care. Facility policy on Change of Condition, revised 09/2025, required nursing staff to notify the resident’s attending physician and family or representative of changes in medication or treatment, significant alterations in medical treatment, and to document in the record who was notified and any new orders. The resident, admitted on 02/28/2025, had diagnoses including dysphagia, major depressive disorder, and type 2 diabetes mellitus, and an annual MDS showing moderately impaired cognition (BIMS score of 11), need for partial assistance with eating, significant weight loss, and receipt of mechanically altered foods. The resident’s durable health care POA, effective immediately upon signing on 12/02/2025, was documented as invoked in the comprehensive care plan.

Record review showed a physician order dated 01/01/2026 directing that the resident be up in a wheelchair for all meals, and that if the resident refused to get up, this would be charted as refusing meals. From 01/01/2026 to 03/02/2026, there was no documentation in the progress notes that the POA was notified of this new order. An RN reported attempting to notify the POA but stated they probably did not document the attempt in the progress notes. The resident’s family member, identified as the point of contact for order changes and communication, reported they were not contacted or notified of the new order regarding being out of bed for all meals and having refusals considered meal refusals. The Interim DON confirmed there was no evidence that the POA was notified of the new physician order and acknowledged that the POA should have been notified.