A resident with memory impairment, moderately impaired decision-making, and dependence for multiple ADLs fell after staff heard a loud crash and found the resident on the floor with the walker nearby. Staff assisted the resident to a wheelchair and recliner, but family notification was delayed until the next morning, despite the resident representative expecting prompt notice after the fall.
Failure to Notify Provider of Abnormal Blood Sugars and Weight Loss: A resident with DM, HF, HTN, and moderately impaired cognition had orders for insulin and bumetanide, but the record lacked documentation that the provider was notified of severe hyperglycemia and hypoglycemia, including blood sugars of 537 mg/dl, 56 mg/dl, and 42 mg/dl. The record also lacked documentation of provider notification for a significant weight loss from 197 lbs to 188 lbs, despite facility policy requiring notification for blood sugars under 70 mg/dl and significant weight changes.
Failure to notify the resident's family and provider of missed alprazolam doses: A resident with anxiety and intact cognition missed six scheduled doses of alprazolam because the medication was on order, and the resident representative was not informed until after asking. Staff and the DON confirmed that the family and provider should have been notified when the medication was unavailable.
Failure to notify physician of a resident’s change in condition and critical blood glucose levels. A resident with DM, CAD, CVA, seizure disorder, malnutrition, depression, and impaired cognition had repeated blood sugars from 376 to 600 mg/dL and increased confusion/agitation. An RN gave sliding-scale insulin and sent a fax, but did not recall calling the MD despite an order to notify the doctor for blood sugar over 400; the DON stated the MD should have been called, especially with the resident’s confusion and agitation.
A resident with Alzheimer’s disease, respiratory failure, and COPD symptoms developed SOB, nausea, dizziness, cyanosis, crackles, and a new productive cough with O2 saturations as low as 70% on 3L NC. Nursing notes documented repeated low O2 readings and abnormal lung findings, but the physician was not notified of the change in condition before the resident was later hospitalized for a COPD exacerbation.
Failure to notify a resident’s guardian of medication and hearing aid changes. A resident with severe cognitive impairment, dementia, chronic pain, and hearing difficulty had hearing aids sent out for repair and a new Fentanyl patch order, but the legal representative was not informed. The guardian stated she had not been kept updated, and the DON acknowledged the guardian should have been notified about the hearing aids.
Failure to Notify Physician and Family of Abuse Allegations: Two residents with severe cognitive impairment were involved in abuse allegations during care. One resident was reportedly grabbed, had a wrist forcefully pushed into the chest, and was yelled at and threatened during a shower; the other resident was reported to have punched a staff member, after which the staff member grabbed the resident's arm. The record lacked documentation that the attending MD and family were notified for either resident.
A resident with dementia, diabetes with neuropathy, and moderate cognitive impairment fell and was later found to have a pelvic fracture. Facility notes were entered late and gave conflicting accounts about whether the PCP, family, and manager were notified. Interviews and provider records showed the NP did not receive timely notice of the fall, and staff stated the RN did not call the family or manager on call after the incident.
A resident with intact cognition and diagnoses including cirrhosis, DM, irregular heartbeat, and HF repeatedly refused ordered lactulose for several days, but the son/DPOA was not timely informed of the refusals. Although staff documented some refusals and the son was present at times, the record did not show that he was told about the prior missed doses, despite the care plan and facility policy requiring family notification when there is a significant change or a need to alter treatment.
Failure to Notify Physician and Family of Missed Scheduled Medications: The DON documented missed evening meds for two residents, including a high-risk med (Eliquis) for one resident and multiple scheduled meds for both residents. One resident had no cognitive impairment and the other had severe cognitive impairment. The DON confirmed the physician and families were not notified of the missed doses, and the facility policy did not give guidance on missed prescribed meds, including high-risk meds.
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