Failure to notify the resident, POA, and attending MD of a dental appointment and tooth extraction led to a resident returning with uncontrolled gum bleeding and transfer to the hospital for oral hemorrhage. Staff reported the scheduler may inform family, but the resident's representatives said they were never contacted by the facility or dental office and would have attended the appointment if they had known.
Failure to notify family of change in condition: A cognitively intact resident had a new order for IV ertapenem for UTI/proteus in urine, and staff documented an unsuccessful IV attempt and DON involvement, but there was no documentation that the resident’s family or responsible party was notified. The DON stated staff are instructed to notify family and document it when a resident has a change in condition, including when the resident was transferred to the hospital and diagnosed with UTI and prescribed antibiotics.
A resident fell in her room and the physician was notified, but there was no documentation that the POA was informed. The RN stated she did not call because it was early in the morning and she planned to wait until waking hours, but never did. The resident said staff did not ask if she needed hospital care, and the facility policy required notification of the physician and family after any fall.
A resident developed a significant bruise to the right breast/armpit area, and although an internal incident report said the POA/family member was notified, the resident's medical record did not document the bruise or the notification. The POA later stated she was not told about the bruising and expected to be called. Facility policy required prompt notification of the resident, legal representative, and attending physician, with notification attempts documented in the nurse's notes.
Failure to Notify Physician of New Skin Tear: A resident with existing venous stasis ulcers was found by an RN to have blood in the toilet and a new small open area on the right labia. The chart showed the groin skin impairment was new, but no treatment was obtained, the care plan was not updated, and the medical record did not show notification of the MD or DON.
Failure to notify physician of a resident’s critical low blood glucose. A resident with recent DM med changes and prior critical glucose levels had a BG of 55 mg/dL, below the physician’s call parameter, but the chart did not show MD notification. Later records documented severe decline, including no pulse, no respirations, and death. An RN reported giving oral glucose, IM glucagon, juice, and IV dextrose, but these interventions and notifications were not documented on the MAR, and the NP stated she was not notified.
A resident developed wounds on both heels, including bogginess on one heel and an intact blister on the other, and the physician was notified with new treatment orders entered. However, the resident's HCPOA was not documented as being notified of either change in condition, and the HCPOA stated he discovered the wounds himself. The DON confirmed the record lacked documentation of notification.
A resident with schizophrenia, psychosis, recent delivery, and a court-appointed State Guardian left the facility AMA after insisting on discharge despite staff education. Nursing documented the resident’s departure and an NP was notified, but there was no documentation that the attending physician or the State Guardian was informed at the time of the departure. The guardian later stated she was told after the resident had already left and had not been notified that the resident was discharging.
Failure to notify the provider of elevated blood sugars. A resident with type 2 DM had an order to notify the MD if 2 consecutive blood sugars were greater than 349, but nursing documented three consecutive elevated readings and no communication with the provider was found in the EHR. The DON stated staff should follow orders as written and notify the provider when required.
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.
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