Failure to notify a resident representative of a change in condition: A resident with severe cognitive impairment had an unwitnessed fall, complained of pain, refused ordered x-rays, and later was found to have a fractured R femoral neck before being sent to the hospital. The record did not document that the POA was notified of the x-ray refusal, the fracture results, or the transfer, despite facility policy requiring notification of the resident representative after accidents/incidents and significant changes in condition.
A resident with malnutrition, chronic iron deficiency, and total dependence for transfers developed an unstageable, necrotic pressure injury to the coccyx/sacrum. Facility records showed the wound was first identified by nursing staff, but the resident’s DPOA/POA was not notified at the time of the significant change in condition; the POA later said they only learned of the wound during a separate call about a fall. The NP also reported no documentation that he/she was notified or addressed the wound.
Failure to notify guardian of hospital transfer: A resident with multiple psychiatric and developmental diagnoses became aggressive toward a peer, attempted to push past staff, and then stated a desire to harm self. The NP ordered transfer to the ER for suicidal ideation, but staff only left a voicemail and did not speak directly with the guardian. Interviews showed conflicting views about whether voicemail counted as notification and whether the emergency contact number should have been used for a behavioral crisis; the guardian stated the facility should have called when the resident was sent out.
Failure to notify DPOA after resident fall with injury: A resident with dementia, osteoporosis, and an active DPOA had a fall that was initially reported as non-injury, but later was found to involve significant bruising and pain. Facility staff did not notify the DPOA or hospice team after the fall, and the DPOA first learned of the event from the hospice aide several hours later, after which the resident was sent to the hospital for evaluation.
Failure to notify the physician after a resident’s change in condition. A CNA repositioned a resident with left-sided paralysis and 2-person transfer needs, heard a pop, and the resident immediately complained of leg pain. The incident was reported to an LPN, but the record did not show physician notification, and the resident continued to report left hip pain the next morning.
A resident with ESRD, low blood pressure, and endometrial CA fell out of bed, hit their head, complained of pain, had markedly abnormal VS, and was sent to the hospital via EMT. Facility progress notes documented the fall, symptoms, abnormal VS, hospital transfer, and notification of the ADON and physician, but did not document any notification of the resident representative. Two adult relatives reported they were not informed of the fall or transfer until the following day, one learning this by phone and the other upon arriving to visit and being told by the receptionist, who initially gave the wrong hospital. The Administrator later confirmed his expectation that responsible parties be notified of changes in condition and that such notifications or attempts be documented, which did not occur in this incident.
Failure to Notify Physician and Resident Representative of Change in Condition: A resident with hypotension, impaired cognition, and a care plan to report deterioration had repeated low BP readings and then developed SOB, increased pain, inability to swallow, low O2 sats, weakness, and inability to stand. An LPN documented the decline and oxygen use, but the record did not show timely notification of the physician or the resident’s representative, and a later very low BP reading was also not reported to the charge nurse or physician.
A resident with schizoaffective disorder, bipolar type, and undifferentiated schizophrenia, who had a legal guardian and impaired thought processes noted on the care plan, sustained an unwitnessed fall in the dining room, reported dizziness, and was assessed by nursing staff who suspected a possible head injury and arranged transfer to the hospital. Although the facility’s incident policy required prompt notification and documentation of contact with the resident’s representative, the legal guardian was not notified at the time of the incident or before the hospital transfer and reported learning of the hospitalization later, with the hospital also not informed of the guardianship status. The LPN on duty admitted forgetting to call and not documenting the later notification, and leadership confirmed that this did not meet their expectation for timely guardian notification after significant events.
A resident with schizoaffective disorder and a history of stroke and brain dysfunction underwent multiple gradual dose reductions and discontinuations of Depakote and Seroquel ordered by a psych NP, but the resident’s representative was not notified of these medication changes. Facility policy required informed consent and notification of legal representatives for medication regimen changes, yet progress notes and the medical record contained no documentation of such notification or any request by the representative to forgo notifications. The DON reported she believed the guardian did not want to be contacted and therefore had not notified the representative about medication changes, while the Administrator stated she expected policy to be followed and notifications documented.
A resident with severely impaired cognition, dysphagia, and a feeding tube had decreased alertness, low O2 sat on NC, and abnormal lab results including elevated BUN, Na, Cl, BUN/Cr ratio, and WBC. Staff did not document notifying the MD about the change in condition or the low O2 sat, and the lab results were only faxed later. The resident's rep later contacted the MD, who ordered hospital transfer for evaluation and treatment; hospital records showed acute hypoxic respiratory failure, sepsis, hypernatremia, and dehydration.
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