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.
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.
A resident with a history of hip fracture experienced a fall while attempting an independent transfer from a wheelchair to bed. Staff responded, initially noted no injury, and obtained STAT X‑rays of the resident’s right upper extremity, which later showed findings consistent with a radial neck fracture of indeterminate age. Although facility policy required timely notification and documentation of changes in condition, accidents, injuries, and diagnostic results to the physician, resident, and family/responsible party, the medical record contained no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. In interviews, an LPN, an RN, the DON, and the Administrator all confirmed that such notification and documentation were expected but had not occurred in this case.
A resident with dementia and a history of falls was startled by a door opening on a locked memory care unit, fell onto the right side, and exhibited pain responses when the right leg was touched. Facility staff notified hospice, and a hospice nurse later assessed the resident, documented no pain complaints and no new orders, and stated they would inform the family. However, facility records contained no documentation that the resident’s responsible party was notified on the day of the fall, and there was no follow-up by facility staff to verify that hospice had contacted the family, despite staff and leadership acknowledging that nurses are responsible for immediately notifying responsible parties of changes in condition and that this notification should occur regardless of hospice involvement.
Staff failed to follow facility policy requiring prompt notification of a change in condition and treatment refusals. A resident on hospice for a short stay was found with a lump on the forehead of unknown cause, which an LPN assessed but did not report to a physician or the resident’s representative. On a separate occasion, the same resident refused all scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa, without any documented notification to the attending physician, hospice physician, hospice staff, or the resident’s representative. In subsequent interviews, the LPN acknowledged forgetting to notify anyone, and the administrator, resident representative, attending physician, and hospice physician all stated they had not been informed and would have expected notification.
The facility failed to follow its own policy requiring prompt notification of a resident’s representative and physician after significant condition changes, including falls with injuries. A resident with Parkinson’s disease, mobility limitations, and a known fall risk experienced multiple unwitnessed falls resulting in a skin tear and a forehead hematoma. Nursing notes and fall tracking tools documented these events but did not show that the resident’s representative was notified. Staff interviews confirmed that family notification was either omitted or deferred between shifts, and leadership stated they expected all falls and notifications to be documented, which did not occur.
A cognitively intact resident with dementia and rheumatoid arthritis experienced multiple changes to colchicine and methotrexate orders, including holding, resuming, dose adjustments, and conversion from PRN to scheduled dosing, without documented notification to the resident or listed emergency contacts as required by facility policy. Additionally, the resident was transferred by ambulance to a hospital for abnormal vital signs with no documentation that family was informed. Family members reported they were not notified of these medication changes or the hospital transfer and only learned of the hospitalization through a third party. An LPN acknowledged nurses were supposed to notify families of significant changes and transfers, while the DON stated staff did not view family notification for medication changes as required when the resident was his/her own responsible party unless specifically requested.
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