Failure to notify the physician when a resident left AMA. A resident became agitated after being brought to the wrong unit, finding the room's AC broken, and having trouble getting a urinal. The resident's daughter later took him home, but the record did not show that the MD was notified, and the AMA form was not signed by the physician.
Incomplete discharge documentation for a resident: The facility failed to accurately and completely document where a resident was discharged, including missing Resident/Representative Acknowledgement information and unclear identification of the discharge destination. A social worker note stated the resident wanted to go home to an address not listed on the admission record and that his brother would pick him up, while staff interviews showed uncertainty about which brother transported him and the DON stated the discharge location should have been documented.
Failure to notify the physician and family of changes in condition occurred for one resident with repeated hypoglycemia and three residents with skin tears or wounds. An LPN did not notify the provider about low blood sugar readings requiring treatment, and staff could not find documentation of skin tear or wound assessments, provider notification, or resident representative notification for the other residents. Facility policy required notification when a resident had a skin tear or a change requiring new treatment.
Failure to Notify Physician of Abnormal Catheter Output: A resident with recent coccyx surgery, chronic pain, and a catheter had dark orange-red, cloudy urine and reported thirst, weakness, and abdominal pain, but staff did not document a CIC or notify the physician. An LPN confirmed the urine was concentrated and miscolored, a CNA said changes should be reported to the nurse, and the DON stated the abnormal catheter findings should have been assessed and reported to the MD.
A resident developed worsening symptoms including chest pain radiating to the back, sweating, clamminess, pallor, vomiting, and repeated requests to go to the hospital. Staff repeatedly raised concerns to the APRN and DON, but the physician and family were not notified of the significant change in condition, and no change-of-condition process was completed.
Failure to Notify Representatives of Significant Weight Loss and New Wound: The facility did not notify a resident’s representative about significant wt loss after weekly weights showed a marked decline, and the RD acknowledged the son was not informed about the loss or dietary changes. The facility also did not document notifying another resident’s representative when a new chin wound from collar pressure was found; the LPN recalled seeing the wound and placing a wound care consult, but was unsure whether the family was called.
A resident with vascular dementia and severe cognitive impairment, admitted for a short hospice respite stay, was discharged from the facility by his daughter without documented verification of her authority or notification and agreement from his listed emergency contact, his spouse. Staff, including an LPN and an RN, relied on the daughter’s statements that the resident’s wife wanted him home and did not independently contact the spouse, and facility records lacked documentation of any attempt to notify the responsible party or confirm consent before the resident left.
Failure to notify the physician and family of a resident’s skin change. Weekly skin assessments documented bilateral lower arm bruising/discoloration, but progress notes did not show notification to the MD, family, or administration. Staff later stated the resident had chronic itchy skin and rubbed his arms on the bed rail, but the behavior was not found in the care plan documentation.
Failure to Notify Physician and Family of Change in Condition: A resident with asthma, trach, G-tube, and ventilator dependence had multiple acute changes, including a blocked GJ tube and severe desaturation with tachycardia, leading to hospital transfers. The record did not clearly show physician notification for one event and did not document physician or family notification for another transfer, and there was no documentation of the circumstances or notifications for a later hospital send-out.
Two residents experienced significant changes in condition without timely notification to their representatives and, in one case, the physician. One cognitively impaired resident with multiple serious diagnoses suffered a cardiac arrest; staff initiated CPR, called 911, and transferred her to the hospital, but documentation showed only the resident herself was listed as notified, and her healthcare proxy later reported she was never contacted by the facility and learned of the event from the hospital. Another cognitively intact respite resident developed skin tears to the arm and leg, reportedly related to an outing incident, which were documented on CNA task lists but not reflected in nursing progress notes or the discharge summary; his daughter discovered a bandage at pickup and stated she was never informed of the incident or injuries despite attempts to reach facility leadership. The DON acknowledged that a change in condition should have been documented and that the nurse, MD, and family should have been notified, contrary to the facility’s own change-in-condition policy.
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