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.
A resident with a history of stroke, dementia, atrial fibrillation, dysphagia, and multiple other conditions was admitted on multiple oral meds, including an anticoagulant. One day after admission, staff documented that morning meds were not given and later noted the resident refused all meds due to difficulty swallowing, describing pooling of water and applesauce with crushed meds in the mouth and removal of the meds without ingestion. The nurse held the medications for the rest of the day and did not contact the provider about the missed doses or swallowing difficulty, while another nurse later reported administering the evening meds crushed in applesauce after extended effort. The physician and corporate nurse consultant later stated the MD should have been notified when the resident could not swallow medications.
A resident with a history of subdural hemorrhage, rib fractures, DM II, weakness, and unsteadiness fell after using the call light for bathroom assistance that was not answered, then attempted to ambulate alone and fell, reporting immediate severe right leg pain. Night-shift staff later lifted the resident from the floor, assisted with toileting, and returned the resident to bed without performing an assessment, documenting the fall, or notifying the MD, NP, or responsible party, despite the resident’s pain and verbal complaint. The oncoming nurse was not given a report of the fall. The next morning, a NA and a medication aide noted the resident’s significant pain and change in appearance, and the UM’s assessment found right leg pain, inability to bear weight, and limited ROM. Pain scores remained elevated throughout the day. Only after the UM’s involvement were the provider and family notified, imaging ordered, and a right hip fracture identified, demonstrating a failure to immediately notify the physician and responsible party of a change in condition following a fall.
A resident with type 2 DM had a new weekly semaglutide order entered into the EMR, but the drug was not available on multiple scheduled administration dates and was not actually given. An RN documented on the MAR that the dose was administered on one date and refused on another, later acknowledging these entries were incorrect and that the medication had been unavailable. There was no documentation that the MD/PA was notified that the ordered semaglutide was not being administered, and the PA reported she was unaware the medication had not been delivered or given until weeks later. The Administrator confirmed that providers are to be notified whenever a resident does not receive a prescribed medication, regardless of unavailability or refusal.
A resident with multiple comorbidities, including Type 2 DM, had a critically high blood glucose one week before a fatal decline, with only a one‑time insulin dose ordered and no ongoing BG monitoring documented afterward. Over the next several days, staff observed new respiratory symptoms, increasing sleepiness, markedly reduced oral intake, inability to drink through a straw, and decreased responsiveness, yet nursing staff notified the NP only of a cough and obtained an order for a CXR, without reporting the resident’s altered mental status, poor intake, or prior critical BG. Vital signs and BG checks were not consistently obtained despite these changes, and no additional provider consultation occurred until the resident was found extremely hot and in respiratory distress, prompting EMS transfer and subsequent death in the ED. Surveyors cited the facility for failing to notify the physician of all observed changes in condition and for not securing appropriate monitoring and treatment orders.
A resident with diabetes and diabetic polyneuropathy had a standing order for Gabapentin 800 mg three times daily, but multiple doses over several days were not administered because the medication was missing from the med cart. Medication aides and nurses documented the missed doses and reordered the drug through the electronic system, and one aide reported informing the nurse on duty, but no staff notified the NP or other provider as required by facility protocol. The unit manager was not informed of the missing medication, and the NP later stated she had been unaware of the missed doses and that the facility should have contacted her.
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