Failure to Timely Notify Physician for Worsening Cough: A resident with CHF, edema, and other cardiac diagnoses developed a persistent worsening cough with SOB and severe discomfort after being placed on comfort care and do-not-hospitalize orders. Staff gave PRN morphine and cough syrup with little relief, but the RN and DON knew about the decline and relied on faxing the MD rather than timely direct notification. The care plan did not reflect the comfort care orders or guidance for managing a change in condition.
A resident with severe cognitive impairment, diabetes, and an existing heel PI developed a new ischemic/necrotic change to the right first toe, but the facility did not notify the PCP or wound care provider as ordered. The toe change was documented on a skin audit and later observed as black on the top of the toe, yet the wound team was not updated and the wound later measured larger than when first identified.
The facility failed to notify the provider of a significant orthostatic BP drop for one resident and failed to notify the provider after two blood glucose readings over 400 mg/dL for another resident. One resident had intact cognition, antipsychotic use, and an order for monthly orthostatic BP checks, but the EMR showed a systolic drop from lying to standing without provider notification. Another resident with type 1 DM and severe cognitive impairment had orders to update the provider for BG >400 mg/dL, yet EMR review showed readings of 498 mg/dL and 449 mg/dL with no documented provider notification.
A resident with CAD, DM, morbid obesity, and debility was not told before taking an LOA that it would end his Medicare Part A coverage. After the resident returned, the MDS nurse issued a NOMNC and therapy services ended because he no longer qualified for skilled coverage. The DRS said he learned of the discharge after the LOA had already occurred, and the resident stated he had only been given medication instructions and meds for the trip, not notice that the LOA would affect coverage.
A resident with moderate cognitive impairment and an activated POA had repeated refusals of care and treatment, including labs, weights, bowel meds, and other treatments, but the facility did not document notifying the POA. The care plan and orders lacked direction for staff on when to notify the provider or POA about refusals, and there was also no documentation that the POA was notified before the resident went to the ER after a fall.
A resident with dementia, epilepsy, and a mechanically altered diet had choking and possible aspiration episodes during meals, including coughing, vomiting, and difficulty chewing and swallowing. Staff notified hospice after one episode, but the record did not show that the guardian/family was notified of the resident’s change in condition, despite staff interviews and facility policy stating that the representative should be informed of significant changes.
A resident with chronic hepatic failure and alcoholic cirrhosis was ordered Lactulose three times daily for bowel management, but the MAR showed that only a small fraction of ordered doses were administered over a month and that multiple subsequent doses were refused. Despite a provider notification form noting ongoing refusals and staff interviews acknowledging frequent medication refusals, there was no documentation in progress notes that the physician was notified of the repeated Lactulose refusals, and the physician’s visit note did not address them. Staff demonstrated limited understanding of the purpose of Lactulose and monitoring needs, the care plan lacked specific interventions for hepatic failure/cirrhosis beyond bowel management, and the DON was unaware of current documentation practices, contrary to the facility’s Notification of Changes policy requiring prompt physician consultation.
A resident with heart disease and severe cognitive impairment was sent to the ED three times for respiratory changes including crackles, wheezing, shortness of breath, hoarse voice, and low O2 saturation, but the facility had no documentation that the provider was notified for any of the transfers. Staff notified family and the on-call nurse/DON, and an LPN stated the facility would send residents out without calling the provider first; the DON stated a provider would not necessarily be notified when a resident’s condition changed requiring ED transfer.
A resident admitted with lumbar stenosis and other postprocedural state left the facility AMA, but the medical record lacked documentation that the primary physician was notified. Notes showed the resident's wife took the resident home and requested medications, the nurse educated them about AMA and did not release the medications, and a spine center later called to verify the resident had left AMA without meds. The ADON/IP confirmed the physician was not updated, and the DON stated the provider needed to be notified when a resident left AMA.
A resident with diabetes, kidney disease, heart failure, and a history of refusing care repeatedly refused ordered Nystatin powder, but staff did not timely notify the provider of the ongoing refusals. Staff interviews showed the resident often would not allow the powder to be applied, and the NP stated she had not been informed of the repeated refusals. A second resident with chronic respiratory failure and an order for continuous oxygen was observed without oxygen in use multiple times, and the PCP stated the facility should have sent an SBAR and updated vital signs regarding the ongoing oxygen need.
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