Failure to Notify Family of Hospital Transfer: An agency RN found a resident with toe pain and suspected larvae under the toenail, called the PCP, and sent the resident to the hospital by ambulance. The RN did not notify the resident’s family member before the transfer, and the family member later learned of the hospitalization from the hospital. Hospital records documented a foot infection with maggots in the wound.
Failure to notify physician of a resident's stroke-like change in condition. A resident with multiple diagnoses and moderate cognitive impairment developed facial droop, slurred speech, weakness, shortness of breath, and difficulty swallowing. A CNA reported the resident did not seem like himself and notified an LPN, then saw the symptoms worsen the next day before the resident was sent to the hospital. The LPN did not recall the report, and the MD stated he did not recall being notified of the change in condition.
A facility failed to notify a resident’s POA after an incident in which another resident entered her room, pinned her against the wall, and was confused about the room. Staff documented redness to the resident’s forearm and shoulders, separated the residents, checked vital signs, and contacted the MD, but the POA said she was never called even though the resident later told her about the event. The DON and administrator stated the doctor and family/POA should have been notified.
Failure to notify the physician of resident changes in condition. A resident with a right hip/femur fracture and severe cognitive impairment had escalating hip pain, belligerence, and repeated 911 calls for hospital transfer, but the record did not show MD notification of the increased pain. Another resident with multiple chronic conditions and severe cognitive deficit developed dark malodorous urine, decreased intake, drowsiness, and vaginal discharge, yet the chart did not document physician notification and the physician office later reported no communication from the facility.
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.
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