Failure to Notify Physician of Fentanyl Patch Error: A resident with severe cognitive impairment, chronic pain, and multiple comorbidities had a fentanyl patch applied without being activated because the plastic backing was left on. The error was documented with increased PRN morphine use, but the clinical record lacked documentation of the medication error and the PCP was not notified, despite facility policy requiring prompt reporting to the physician, resident, and/or responsible party.
A resident receiving clopidogrel developed a nosebleed, nasal swelling, and facial edema, but staff did not document notifying the provider or family when the bleeding first occurred. The resident declined immediate doctor or ED contact, later required EMS transport after family noticed swelling, and was admitted to the hospital with a brain bleed. Staff stated the provider needed notification because the resident was on an antiplatelet medication.
Failure to Notify Physician of Abnormal Blood Sugars and Missed Insulin: A resident with DM, HF, HTN, renal failure, and COPD had ordered insulin and accuchecks, but the MAR lacked documentation for missed insulin and missing BG results. Several BG readings were outside ordered parameters, yet there was no documentation that the physician was notified, and the DON could not find an explanation for the omitted insulin or missing BG checks.
A resident with intact cognition had a missed famotidine dose because the medication was not available on admission. The PCP and POA were notified later, but staff interviews showed the expected timeframe for family notification was within 45 minutes to 24 hours, and the DON stated notifying the family 5 days later was not appropriate. The facility policy required prompt notification of the resident, physician, and resident representative, generally within 24 hours.
A resident with significant psychiatric history and cognitive impairment had multiple psych med changes made without notifying the guardian/POA or consulting the psychiatrist of record, despite the guardian’s direction that psych meds be managed by the psychiatric hospital. Another cognitively impaired resident developed a firm, distended abdomen with nausea, vomiting, constipation, and ongoing abdominal pain, but the physician was not notified until 6 days later, after the resident’s condition worsened and she was sent to the ER.
The facility failed to notify the physician and/or family when residents had significant changes of condition for 3 residents reviewed. One resident with severe cognitive impairment and multiple diagnoses had a significant weight loss, but the record lacked documentation that the family was notified. Two residents had choking episodes during meals; staff documented assessment findings and symptom resolution, but the records lacked documentation that the physician was notified. The DON stated family notification was expected for the weight loss and physician notification was expected for choking episodes.
Delayed notification of resident falls to family and Hospice. Two residents with cognitive impairment and significant care needs experienced multiple falls, but staff did not promptly notify the legal representative or Hospice provider after the incidents. One resident's wife was upset that she was not called after consecutive falls, and another resident's representative said he received notice hours later or the next day instead of right away.
The deficiency involves the facility’s failure to immediately notify a family member and a physician of significant changes in condition for two residents. One resident with moderate cognitive impairment and multiple complex diagnoses fell during an assisted bathroom transfer, hit her head, sustained a leg skin tear, and complained of back pain; although the RN notified the on-call physician and later obtained an order to send the resident to the hospital for unmanaged pain, the resident’s daughter, listed as the primary emergency contact, was not called until about three hours after the fall. In a separate case, another resident with moderate cognitive impairment, osteoporosis, prior vertebral fracture, and recent knee pain after a reported fall had bilateral knee x-rays, which revealed a comminuted right patellar fracture marked as a critical finding; an LPN received the faxed result shortly after midnight but did not call the on-call provider, instead sending texts to management, and the provider was not notified of the fracture until later that morning by the Administrator. These actions did not comply with the facility’s policy requiring immediate notification of the resident, physician, and family for accidents, significant changes in status, or the need to significantly alter treatment.
A resident with intact cognition and diagnoses of adult failure to thrive, diabetes, and cancer had an order for zinc sulfate on the MAR, but the medication was documented as unavailable over several days and was not administered. There was no documentation in the progress notes that the provider was notified of the omitted zinc sulfate, and the Administrator confirmed that such documentation could not be found. Review of the facility’s Medication Administration-Medication Pass policy showed it did not include a process for what staff should do when a medication is not available.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
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