A resident with dysphagia choked while being fed dinner by staff. An LPN assessed the resident, used back blows to expel the food, and the resident returned to baseline with stable VS, but the physician and RP were not notified of the change in condition. The RN supervisor was aware of the event, and the physician later stated he expected notification of any resident change in condition.
A resident with diabetes and sleep apnea missed multiple tirzepatide doses over several months, and staff documented reasons such as waiting on pharmacy, reorder, or medication not being in stock. However, there was no documentation that the physician or NP was notified of the missed doses, and nurses later stated they had not called the provider or obtained an order to hold the medication. The resident reported missing doses for months, and the physician, NP, DON, and Administrator were unaware the doses had not been reported.
A resident with TBI, dysphagia, quadriplegia, and gastrostomy status had repeated vomiting episodes while receiving bolus tube feedings, but nursing staff did not consistently notify the provider when feedings were held. A KUB showed constipation with possible fecal retention and dilated bowel loops suggesting obstipation and/or ileus, yet the results were not promptly communicated to the provider. The resident later deteriorated with respiratory distress, hypotension, unresponsiveness, and aspiration-related complications before dying in the hospital.
A resident with venous insufficiency, varicose vein ulcers, and DM had bilateral lower leg wounds that became open, blistered, and weeping, but the nurse did not notify the MD/NP or initiate treatment, and no wound orders were in place. In a separate event, after another resident expired, the nurse documented limited contact attempts and the DON was informed, but the RP and other emergency contacts reported they were not notified of the death.
Failure to notify MD/PA of changed pain and incomplete imaging: A resident with chronic pain, DVT, PAD, dementia, and prior R tibia ORIF reported being dropped during a transfer and then developed worsening R knee/leg pain with inability to tolerate turning and care. Staff gave PRN tramadol and topical analgesic, but communication about the change in condition was inconsistent, the PA was not promptly notified, and additional x-ray orders were entered without first contacting the physician. When the x-ray tech could only obtain one view because of pain and the radiology report recommended repeat standard views, the physician was not notified; the resident was later sent to the ED, where a distal R femur fx was found.
A resident with diabetes, recent G-tube placement, and enteral feeding orders had a fingerstick blood sugar of 509 that was not reported to the provider. The RN did not recheck the glucose or call the MD because the resident appeared alert and without symptoms. The next morning the resident was found nonresponsive, EMS noted fever, hypotension, tachycardia, and tachypnea, and the hospital documented DKA/HHS with a serum glucose over 1000.
A resident with ESRD and stroke history had a fistula/shunt bleeding event during dialysis and was transferred to the ED, but the facility did not notify the MD or RP. Staff interviews showed the nurse assumed dialysis would make the notifications, while the DON, PA, and Administrator stated the facility should have informed the MD and RP once the transfer was known.
A nurse administered subcutaneous fluids to the wrong resident after confusing two roommates and using the incorrect resident’s profile in the automated dispensing system. She later stopped the infusion and started the fluids on the correct resident, but did not assess the affected resident or notify the MD, resident, or responsible party. The resident later reported the incident, and the responsible party and MD stated they had not been informed.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO twice daily, but over several days eight doses were not administered because the medication was unavailable or awaiting pharmacy delivery. Multiple nurses documented the missed doses on the MAR yet did not notify the physician, with some stating they did not think or realize notification was necessary. The DON stated she expected staff to notify the provider when medications are unavailable, and the physician reported being unaware of the missed doses and stated that medications should be administered as ordered and that the provider should be notified if a medication is not available.
A resident with dementia, failure to thrive, a fall history, and HTN was found on the floor by an RN, who assessed for pain and injury but did not notify the NP, responsible party, DON, or Medical Director of the fall and entered the event in the EMR as an injury rather than a fall. Two days later, the resident reported new right knee pain and swelling; the NP and family were informed only of the pain, not the prior fall, and an x-ray was ordered. Over the following days, the resident continued to report pain, received multiple analgesics, and underwent imaging, culminating in a CT that showed multiple right hip and pelvic fractures. The NP, Medical Director, and resident representative all reported they were not made aware of the fall until after the CT results and subsequent internal review, and hospital records later documented admission for a displaced right acetabular fracture and severe pain with functional decline after a fall at the facility.
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