Failure to notify physician and guardian of missed antipsychotic injection and behavior changes. A resident with schizoaffective disorder, dementia with behavioral disturbance, and severe cognitive impairment missed a scheduled monthly Invega Sustenna injection, and the dose was not given until weeks later. The MAR and EMR showed no documented notification to the MD or guardian when the medication was missed, and progress notes later documented refusal of oral meds and increased anxiety and agitation without notification. The resident then had escalating psychotic and aggressive behaviors, multiple hospital transfers, and admission to a behavioral unit.
A resident with Parkinson’s disease, repeated falls, and moderate cognitive impairment fell and then developed worsening pain, swelling, and inability to bear weight. Staff documented an initial call to the physician’s office, but there was no timely follow-up or continued notification when the resident’s condition declined. The physician later stated he was not informed of the fall or the severity of the resident’s pain and swelling until a text message was sent, and the resident was subsequently found to have a femur fracture.
A resident with multiple cardiac and neurologic diagnoses experienced a rapid weight gain of over 17 pounds in less than two weeks, along with shortness of breath and +3 to +4 pitting edema. Facility policy and the resident’s care plan required staff to notify a physician or APRN of weight changes of three pounds in one week and abnormal assessment findings, but nursing staff and the DON documented successive weight increases and respiratory symptoms without evidence of provider notification. The APRN reported not being informed of the repeated weight gains until the day an LPN finally contacted him, obtained orders for diagnostic tests and IM furosemide, and sent the resident to the hospital at the request of a family member who had repeatedly voiced concerns about worsening edema.
A resident with a seizure disorder and significant respiratory and neurologic conditions had an order for Vimpat twice daily and another anti-seizure medication. Over several days, multiple doses of Vimpat were documented as not available and not administered, with no evidence the physician was notified. Later, an LPN administered double the ordered Vimpat dose, and the resident experienced a change in condition and was sent to the hospital. Documentation claimed that the physician and responsible party were notified promptly, but the medical providers and responsible party reported they were not informed of the missed doses, the overdose, or the transfer by facility staff. Other staff interviews indicated the LPN realized the error during shift change and told the weekend supervisor, who expected the LPN to notify the provider and responsible party but did not verify that this occurred, contrary to facility expectations and policy.
Delayed STAT Pain Medication Order Not Reported: A resident with chronic pain syndrome and a left wrist fracture had a STAT tramadol order after an unwitnessed fall, but the medication was delayed by the pharmacy and not promptly reported to the NP, MD, or management. Nursing staff contacted the pharmacy about the delay, but an LPN stated she did not notify the NP or MD, and both providers said they were not informed of the delayed delivery.
Failure to Notify MD and Family of Significant Change in Condition: Staff did not promptly notify the MD or resident representative when a resident with DM, ASHD, and full code status had decreased PO intake, low fluid intake, and a change in LOC/mental status. CNA, LPN, and RN observations showed the resident was sleepy, not opening eyes, and not eating or drinking, but there was no documented notification until the resident became unresponsive and was sent to the hospital, where she was diagnosed with intracerebral hemorrhage, sepsis, and pneumonia.
Failure to notify the physician of missed medications for two residents. One resident with severe cognitive impairment and diagnoses including HTN, DM, depression, psychotic disorder, and GERD repeatedly missed scheduled AM meds because he was asleep. Another resident with severe cognitive impairment and HTN repeatedly missed ordered antihypertensives, including amlodipine, lisinopril, and Lopressor, on multiple occasions. The Medical Director stated she was not aware the residents were not receiving their meds, and the DON and ED stated staff should notify the physician when medications are not administered.
Failure to Notify Resident Representative of Significant Change in Condition: A resident with severe cognitive impairment, pressure injuries, traumatic subdural hemorrhage, and malnutrition developed a new DTI and received new wound care orders from the APRN, including an x-ray to rule out osteomyelitis. There was no documented evidence that the POA was notified of the change in condition or the new orders, and the POA stated the facility had not communicated how serious the wounds were or that the resident had a bone infection and antibiotics.
A resident with severe cognitive impairment and multiple medical conditions developed significant bruising on her chest, which was observed by nursing staff and assessed by the DON. However, the resident's family was not notified of the injury until several days after it was first identified, resulting in a delay in communication about the resident's condition.
A resident who was full code expired in the facility, and staff failed to initiate CPR and failed to immediately notify the physician or on-call NP. The resident had significant cardiac and cerebrovascular history, was found without pulse or respirations, and the NP was not notified until more than an hour later. Interviews showed staff expected immediate notification, but the DON did not notify the physician and the NP later confirmed the delay.
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