Failure to Notify POA and Providers of Significant Changes in Condition
Summary
The deficiency involves the facility’s failure to notify resident representatives and providers of significant changes in condition for two residents. For one resident with traumatic hemorrhage of the right cerebrum, carotid artery aneurysm, convulsions, and a cognitive communication deficit, the face sheet and POA documents identified the spouse as POA and first emergency contact, and the son as second emergency contact and secondary POA. Social services documentation and nursing notes showed that this resident explicitly stated that her husband should be the first person notified of any changes in condition and her son the second. Despite this, multiple SBAR forms documented repeated changes in condition, including abnormal vital signs with unresponsiveness, new swallowing issues, a positive COVID test, swallowing difficulties, a fall with head injury, an altercation with another resident, a seizure, and another fall. In each of these events, staff notified only the resident’s daughter‑in‑law, identified as the resident representative, and did not notify the husband or son as emergency contacts/POA. Interviews further confirmed the pattern of non‑notification of the appropriate decision‑makers for this resident. The son reported that the facility did not notify him after any of the resident’s changes in condition and that he learned of these events from the resident representative instead. The husband/POA stated he did not recall being notified by the facility regarding any of the changes in condition and did not know who the facility contacted. The resident representative stated that staff began contacting her instead of the husband and son, sometimes because they did not answer the phone, and acknowledged that this practice bothered the son. The Unit Manager stated that facility nursing staff were required to call the POA and emergency contact for any change in condition and that if a family member onsite was not the POA, staff should still notify the POA. She acknowledged that nursing staff should have contacted the resident’s husband or son regarding the changes in condition, even when the resident representative was present in the facility. For the second resident, who had dementia with behavioral disturbance, chronic respiratory failure with hypoxia, chronic CHF, and hypoglycemia, and who was documented as full code with all interventions, the facility failed to notify a provider when the resident exhibited an acute change in condition. Nursing progress notes documented that in the early morning hours, the resident was mouth breathing with gurgling sounds in the deep throat, had non‑productive coughing, an oxygen saturation of 92% on 3 liters of oxygen, and was uneasily aroused by tactile/verbal stimuli, with abnormal lung sounds including bilateral upper lobe rhonchi and diminished lower lobe sounds. The nurse recorded that the primary care physician was made aware via a non‑emergent in‑house communication log for further evaluation and treatment, and that the oncoming nurse would be informed. Later that morning, the nurse was called to the resident’s room and found the resident unresponsive, with CPR initiated and a code blue performed by EMS, and the resident was pronounced dead. Additional interviews and documentation clarified that the nurse practitioner considered the information placed in the non‑emergent provider logbook inappropriate for that communication channel and stated that staff should have called a facility provider and 911 immediately regarding the resident’s status, rather than using the non‑emergent log. The DON stated that the first time she was made aware of the situation was when the code blue was called and that staff were required to notify a provider for any change in condition; review of the on‑call provider log showed no calls for this resident on the relevant dates. A CNA reported that when she arrived, the resident was not responding or opening her eyes, was coughing with gurgling sounds, and appeared very pale, and that she and another CNA could not obtain a pulse before summoning the nurse and initiating the code blue. The nurse who cared for the resident that morning stated she obtained but did not document vital signs, recalled an oxygen saturation of 88% on 2 liters improved to 92% on 3 liters, noted coughing with inability to expel mucus, and believed the resident was at baseline, so she did not call the on‑call provider and instead wrote in the non‑emergent log. The oncoming nurse stated she was told the resident was not awake or alert enough to receive morning medications, did not see the resident until notified by the CNA that the resident was not breathing, and stated that if a sternal rub was necessary, the nurse performing it should have called the provider. These actions and inactions led surveyors to identify an Immediate Jeopardy related to failure to notify providers and representatives of changes in condition.
Removal Plan
- Provide change in condition (CIC) education to LPN and RN staff, including definition of CIC, appropriate communication to providers, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention.
- Ensure all nurses on duty since the event receive the CIC education and understand their responsibility (DON/designee verification).
- Conduct an initial review of the non-emergent provider communication log process with the provider and administration team to clarify appropriate acuity of notifications.
- Require that changes of condition be reported directly to the provider; restrict the non-emergent log to non-emergent patient requests or medication refills.
- Update the non-emergent provider communication log form to reflect the revised process.
- Place the agency nurse who documented the progress note on administrative leave pending review of care.
- Conduct an in-person meeting with the agency nurse by two nurse managers to review documentation and provide one-on-one education regarding substandard care.
- Notify the agency of the event and investigation involving the agency nurse.
- Assess and document vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) on every resident in the facility.
- Have nurse managers conduct room-to-room visual inspections to verify proof of life and resident stability.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
A resident with severe cognitive impairment and a history of falls, weakness, malnutrition, and difficulty walking was found on the floor and later developed persistent right hip, thigh, and RLE pain with inability to bear weight. PT and OT notes documented worsening pain and limited mobility, but progress notes did not show notification to the MD or NP. The resident was later sent to the hospital, where imaging showed a displaced right femoral neck fracture.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
A resident had an unwitnessed fall, but the physician and resident representative were not notified until the next morning. The facility’s policy required prompt assessment and notification after a fall, and the resident had capacity to understand and make decisions. An LVN said the delay occurred because the resident did not show a change in condition, while an RN stated the nurse should have notified the physician and representative immediately after assessing the resident.
A facility failed to notify family representatives about missed morning medications for eight residents. MARs showed blank administration entries for the medication pass, and Progress Notes did not document family notification. Interviews with family members and the POA confirmed they were not told about the medication omissions, while the DON stated notifying families of medication errors is standard practice and should be documented.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Notify Provider of New Right Hip Pain and Inability to Bear Weight
Penalty
Summary
The facility failed to follow its policy for notification of a change in resident condition by not notifying the physician and/or nurse practitioner when a resident developed new right lower extremity pain and inability to bear weight. The resident had a history that included weakness, unspecified fall, hypotension, severe protein calorie malnutrition, major depressive disorder, cognitive communication deficit, metabolic encephalopathy, and difficulty walking, and had a BIMS score of 4/15 indicating severe impairment. After the resident was found on the floor on the right side next to the bed with lacerations, redness to both knees, a laceration to the right ankle, and redness to the right hip, the resident initially denied pain. Subsequent PT and OT documentation repeatedly recorded pain in the right hip, thigh, and right lower extremity, with pain increasing with movement, sitting, standing, bending, and weight bearing. PT notes documented that the resident required walker support, took only a few small steps with max assist due to pain, later became unable to ambulate because of severe right lower extremity pain, and was unable to put weight on the leg and had difficulty standing. OT notes also documented aching right lower extremity pain that limited lower body ADLs and functional mobility tasks. The progress notes did not document notification to the doctor or nurse practitioner about the pain or the changes in the resident's right lower extremity. When the resident was later sent to the hospital at the family’s request, the nurse practitioner and ADON were made aware, and the resident was transported by ambulance. The hospital record documented right hip pain, tenderness to palpation and with range of motion of the right hip, and x-ray findings of a superolateral displaced right femoral neck fracture. The hospital history noted the resident may have fallen two weeks earlier, and the daughter reported the last time she saw the resident walking was four weeks earlier. Staff interviews indicated the APRN and NP were not notified of the pain or inability to bear weight, and both stated they would have assessed the resident and likely ordered an x-ray if they had been informed.
Failure to Notify Legal Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident's legal representative of a significant change in condition for one resident reviewed for notification of changes. The resident was admitted with pneumonitis due to inhalation of food and vomit, dysphagia, and stage 3 chronic kidney disease. The Minimum Data Set dated 05/06/2026 documented that the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. On 05/14/2026, the resident experienced a vasovagal episode while in the shower and later had episodes of vomiting, including brown-colored emesis. Progress notes documented that staff notified the PA of the resident's condition, assessed the resident, and monitored vital signs. The facility policy titled Notification Policy required the attending physician or designee and the resident or resident's legal representative or interested family member to be notified by the nurse of a significant change in condition, including vomiting, change in mentation, change in vital signs, or respiratory distress. There was no documented evidence that Family Member #2 was immediately notified of the vasovagal episode or the vomiting. Family Member #2 stated they were not informed of these events and first learned from the facility when told the resident had passed away at 12:07 PM. Staff interviews confirmed that family notification was expected for significant changes, and the PA stated they were contacted about the vasovagal episode, the vomiting, and later the resident's death.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Delayed Notification After Resident Fall
Penalty
Summary
The facility failed to notify Resident 4’s physician and resident representative of an unwitnessed fall in a timely manner. The facility’s Fall Prevention and Response policy stated that after a fall, a licensed nurse shall promptly respond, assess the resident, and notify the physician and resident representative. Resident 4 was admitted to the facility and had an H&P showing the resident had the capacity to understand and make decisions. Resident 4’s SBAR Fall Report documented a fall on 5/3/26 at 2330 hours, but the physician and resident representative were not notified until 5/4/26 at 0744 hours. LVN 1 stated the resident was monitored closely after the fall and that notification was delayed until the following morning because the resident did not exhibit a change in condition. RN 1 verified the fall occurred and stated the licensed nurse should notify the physician and resident representative immediately after assessing the resident rather than waiting until the next morning. The DON was informed and acknowledged the findings.
Failure to Notify Families of Missed Morning Medications
Penalty
Summary
The facility failed to notify resident family representatives of missed administration of significant morning medications for eight residents. Review of the Medication Administration Records for R1, R2, R3, R4, R5, R6, R7, and R8 showed blank boxes without nurses’ initials to indicate the medications were administered on 5/10/26 during morning medication pass. The residents’ Progress Notes did not document that family representatives were notified of the medication omission errors. Interviews confirmed the lack of notification. On 5/21/26, R8’s POA stated the facility did not notify her that R8 missed medications on Mother’s Day. On the same day, R1’s family member stated she was not contacted about the missed medications, and R2’s family member stated no one called or told him there were problems with his father receiving medications. The Interim DON stated it is standard practice for family representatives to be notified of medication errors, that floor nurses are expected to contact families, and that the notification should be documented in the resident’s medical record. The facility policy on Physician-Family Notification-Change in Condition states the facility will inform the resident, consult the physician or authorized designee, and if known, notify the legal representative or interested family member.
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