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.
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.
The facility failed to notify the physician and, for one resident, the legal guardian, of significant changes in condition. One resident’s worsening hand contracture, delayed OT eval, missed OT frequency, and orthotic intolerance were not reported, and the contracture progressed to finger amputation. Another resident’s worsening bilateral hand contractures and stage 4 pressure ulcer were not reported. Two residents with COPD had empty O2 tanks and low SpO2 readings, but the NP was not notified of the respiratory decline.
Failure to notify the provider of elevated FSBS results for a resident with DM2, ESRD, and dialysis dependence. The resident had multiple blood glucose readings above the ordered threshold, including values in the 300s, 400s, and nearly 500 mg/dL, but the chart lacked progress note documentation showing MD/NP notification. The UM stated provider notification should have been documented and could not provide evidence that it occurred.
A resident with acute on chronic respiratory failure, continuous O2 dependence, obstructive sleep apnea, asthma, and schizoaffective disorder had an order for pulse oximetry each shift with instructions to notify the physician if O2 saturation fell below 90%. Over multiple days, nursing staff recorded several dangerously low saturation readings while the resident was on 3 L O2 via nasal cannula, yet there was no documentation that the physician was notified as ordered. In interviews, the nurse, Unit Manager, and DON all stated they were unaware of the specific parameter to notify the physician when saturation dropped below 90%, and acknowledged that multiple sub-90% readings occurred without physician notification.
A resident with type 1 DM, diabetic neuropathy, ASHD, and dementia had multiple blood glucose readings below 70 mg/dL, but the record did not show that the MD/NP was notified as ordered. The resident’s physician order required notification for blood sugar less than 70 or greater than 400, and the Unit Manager, DON, and NP all stated the NP should have been informed and that such contacts should be documented in the medical record.
A resident with Alzheimer’s disease and moderate cognitive impairment developed two new deep tissue injuries on the buttocks, but the nurse did not notify the attending MD or after-hours coverage when the areas were discovered. The wounds were documented in a skin assessment, yet no physician notification was found in the record and treatment/monitoring orders were not implemented until later; the DON stated new skin areas should be reported even if passed in shift report.
A resident with an invoked HCP and a history of recurrent major depressive disorder was receiving Sertraline 100 mg daily when a consultant pharmacist recommended a GDR to 75 mg. The NP agreed with the recommendation, wrote an order to decrease the dose, and expected nursing to notify the resident’s HCA and obtain approval before implementation. A nurse supervisor transcribed the new order and the resident received the lower Sertraline dose for more than a month, but there was no documentation that the HCA was notified, and the HCA later reported not being informed of the medication change despite having requested that the antidepressant dose not be altered.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation, and with an invoked HCP, was found on the floor by one nurse, who then sought assistance from another nurse. After the resident was assessed and returned to bed, neither nurse completed required fall documentation or notified the physician or HCA, each assuming the other would do so. The fall was not reported to clinical leadership until later, and the physician was not documented as being notified until several days after the event. A family member later observed a bruise near the resident’s eye during a visit and reported that no one from the facility had informed her of the fall.
A resident with multiple medical conditions developed MASD to the coccyx and was assessed by a Wound Nurse Practitioner, who made specific treatment recommendations. These recommendations were not communicated to the physician, no physician's order was obtained, and the treatments were not implemented. Nursing staff and the DON confirmed the expected process was not followed, and the lapse in communication and care was not explained.
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