Failure to Notify Physician of Significant Change in Resident Condition
Summary
The deficiency involves the facility’s failure to consult with a resident’s physician when there was a significant change in the resident’s physical, mental, or psychosocial status. The resident was an adult male with multiple serious diagnoses, including Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a doctor. On one day, his blood pressure readings taken by a medication aide were 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., which were hypotensive. There was no documentation that a Change in Condition (CIC) assessment was completed that day, and no progress notes indicated that the physician had been notified of these low blood pressure readings or of any change in condition. Staff interviews and records showed that the resident’s condition had changed over the same period without appropriate escalation to a provider. CNAs reported that the resident, who was normally alert, communicative, and active on his computer, slept most of the day and night, was very sleepy, did not eat breakfast or lunch except for one cup of pudding, and had minimal verbal communication, sometimes only nodding his head with eyes closed and heavy breathing. A CNA stated he informed the floor nurse that the resident had not eaten and was very sleepy but could not recall the nurse’s name or what action was taken. A medication aide stated he held the resident’s blood pressure medication due to low blood pressure and told an unidentified nurse, but he could not say which nurse or what the nurse’s response was. The nurses who worked those shifts stated they were not informed of the low blood pressure readings or the resident’s poor intake and increased sleepiness. The following morning, an LVN entering the resident’s room found him drowsy, barely speaking, with an untouched breakfast tray, clammy to the touch, and with a low blood pressure of 75/54. The LVN documented that the resident was unresponsive to a sternal rub and was sent out due to an acute change in condition, hypotension, increased work of breathing, and unresponsiveness; EMS, the provider, the DON, and family were notified at that time. Subsequent hospital information obtained by surveyors indicated the resident was admitted to ICU for unresponsiveness, required multiple rounds of CPR after his heart stopped, and was diagnosed with a blood infection, septic shock, mucus in his lungs, and an acute stroke, with a blood sugar of 63. The resident’s primary medical doctor reported that when he saw the resident at the hospital, the resident had vomit around his mouth, appeared to have been deteriorating for hours, and had technically passed away twice but was resuscitated. The facility’s DON confirmed that per policy, providers should be informed of all significant changes, and that CNAs and medication aides were expected to report changes to nurses, who in turn were to notify the provider and document the change in condition, which did not occur in this case. An Immediate Jeopardy was identified related to this failure to notify the physician of the significant change in condition.
Removal Plan
- Removed medication aide #1 from assignment pending completion of in-service training on Medication Administration, reporting abnormal vital signs to charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action for failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process: evaluation/assessment, documentation (vital signs and Change in Condition assessment/progress note), reporting to the medical provider, notification of resident representative, and ensuring all steps are documented in the EHR.
- Required licensed nurses to review medication aide vital sign forms to identify abnormal vital signs, re-assess residents, implement interventions, notify the medical provider and resident representative, and document actions in the EHR.
- Required nurses to report identified/suspected changes in condition to the oncoming nurse during shift handoff to ensure continuity of reporting.
- Prohibited any nursing staff (full-time, part-time, PRN, or on leave) from working their next assigned shift until all required in-service training was completed.
- Educated all certified medication aides on medication administration (rights of medication administration) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process for subtle changes in condition and expectations for use.
- Required Stop and Watch forms to be completed in the EHR and/or on paper, communicated to the nurse, and paper forms turned in to the charge nurse for nurse follow-up assessment and notifications.
- Required nurses to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the DON when a change in condition is identified and Stop and Watch is completed, including confirmation that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse's station.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for state surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication, orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all PRN/on-leave nursing staff are in-serviced prior to working their next shift and that administrative nursing staff provide in-service/education prior to staff working.
- Ensured all residents receive appropriate care after a change in condition.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F580 and the plan of removal to lift immediate jeopardy.
- Required certified medication aides to handwrite all vital signs on the designated vital sign form/log and turn it in to the charge nurse.
- Placed a copy of the medication aide vital sign form/log in the Abatement/Plan of Removal binder for state surveyor review.
- Ensured Stop and Watch forms were available in designated locations for staff access and use.
- Required DON notification by phone when a Stop and Watch form is completed and a change in condition is identified.
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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