Failure to Timely Notify Physician and HCP of Change in Condition: A resident with paraplegia, DM, a chronic stage IV pressure injury, and other chronic conditions reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. Nursing assessed the resident but did not promptly notify the MD or HCP; the HCP was only informed later when she visited and noticed right-sided facial drooping. The resident was then sent to the ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria.
A resident with an activated HCP and severe cognitive impairment developed MASD to the buttocks, and the nurse obtained a new Triad cream order after notifying the NP. The HCA later reported she was not told when the skin breakdown first appeared or when the new treatment began, and the chart contained no documentation that the HCA was notified of the significant change in condition or the new order.
Failure to Notify Provider and HCP After Medication Error: An LPN gave one resident another resident’s morning meds in error after misidentifying the resident in the dining room. The nurse later realized the mistake but did not notify the resident’s MD or activated HCP, and another nurse who learned of the error also did not notify the MD. The DON stated the physician should have been notified right away.
A facility failed to timely notify the physician of a PNP’s medication recommendations for a resident with depression and anxiety who was moderately cognitively impaired and receiving Cymbalta. The PNP recommended decreasing Cymbalta and considering Zoloft due to depressed mood, but the record did not show the recommendation was communicated to the provider; the UM said the recommendations were emailed to her, she missed them, and did not inform the provider.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
Failure to notify clinician of cervical collar non-compliance. A resident with a new cervical fracture, severe cognitive impairment, and a history of rejecting care repeatedly removed or refused an ordered cervical collar that was to remain in place at all times. Staff observed the collar off or not secured on multiple occasions and documented repeated refusals, but the record did not show timely notification of the attending MD, NP, or orthopedic specialist; the DON stated the physician should have been informed when the non-compliance began.
Failure to Notify Provider of Significant Change in Condition: The facility failed to promptly notify the MD/NP of significant changes for two residents. One resident was admitted with a right ankle pressure injury; a unit manager saw the wound during the skin check but did not report it or obtain wound treatment orders, and the physician later identified it as a Stage 4 pressure injury down to the bone. Another resident with CHF had a weight above the ordered threshold for Bumex, but the elevated weight was documented without notifying the provider or obtaining the ordered diuretic.
A resident with multiple chronic conditions and moderate cognitive impairment had a physician order and facility policies requiring notification of the resident’s representative for changes in condition, incidents, and significant care decisions. Nursing staff documented a large bruise on the resident’s foot and later arranged a hospice evaluation after the resident expressed interest, but there was no documentation that the family was notified of either the injury or the hospice consult. The family member reported not being informed by facility staff and only learned of the hospice referral from the hospice RN, while the DON, DSS, and NP all confirmed that nursing was responsible for these notifications and that they were not completed or documented.
Failure to notify the HCP of a resident’s change in condition and significant weight loss. A resident with anoxic brain injury, quadriplegia, and cognitive impairment was sent to the hospital after becoming lethargic, mumbling, and not eating, but the transfer form and SBAR did not show HCP notification, and the HCP said they learned of the transfer from the hospital social worker. The resident also had significant weight loss documented by the RD, but the record did not show HCP notification, and staff stated nursing was responsible for notifying and documenting the HCP.
Failure to timely notify the HCP after a resident with Alzheimer’s disease and dementia was found ingesting and coughing up large chunks of a Styrofoam plate. The NP evaluated the resident for ingestion of a non-food item, and the chart later showed a change in care to remove all non-food items from meal trays, but the HCP was not documented as notified until several days later.
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