A resident with quadriplegia and intact cognition was ordered IM Cefepime BID for a UTI, but the MAR showed multiple missed doses and no evidence the provider was notified. The resident confirmed the medication was not being administered as ordered, and an RN acknowledged the missed administrations were not documented and that the provider should have been informed.
The facility failed to notify the provider of abnormal blood sugars, medications given outside ordered hold parameters, and an increased AIMS score. A resident had multiple blood glucose readings above the ordered notification threshold with no evidence of MD notification. Three residents received antihypertensive medications when BP or pulse were outside ordered parameters, and the DON confirmed there was no documentation that the provider was notified. Another resident's AIMS score increased, but the record did not show provider notification.
Failure to notify the PCP of significant weight gain: A resident had an order for daily weights and PCP notification for any gain over 5 lbs, but several weights were missed and multiple weight increases above the threshold were documented without provider notification in the EHR. The IP confirmed the missed weights and the lack of PCP notification.
The facility failed to notify the practitioner when ordered meds were unavailable for two residents. One resident with osteomyelitis had missed or undocumented doses of ciprofloxacin when the supply ran out, and another resident with frequent pain had no available Butrans patch and later no oxycodone. Progress notes and staff interviews confirmed the meds were not available, the pharmacy was contacted to reorder, and the practitioner was not notified when the supplies ran out.
Failure to Notify Physician and Legal Representatives of AMA Departures: The facility did not document timely notification to the MD/PA-C, guardian, or POA when multiple residents left or failed to return after signing out AMA. One resident with osteomyelitis, quadriplegia, and HTN left with a court-appointed guardian not notified; another resident with severe malnutrition, hepatic failure, and alcohol abuse left AMA without POA notification. Additional residents with metabolic encephalopathy, dementia, DM2, acute respiratory failure, CKD, and other conditions also had no documentation that the physician was notified when they left or did not return.
A resident with severe dementia, behavioral disturbance, depression, cognitive communication deficit, and bilateral glaucoma had head pain and later was found to have a C1 fracture after a fall. Staff did not document fall assessments, and an LPN initially denied the fall before later admitting the resident had been on the floor and was assisted back to a recliner without assessment, documentation, or reporting. The facility also failed to notify the physician and resident representative as required.
Failure to notify the provider of missed weight measurements for two residents. One resident had dysphagia and a g-tube with weekly weight orders, but several weekly weights were not recorded and there was no evidence the MD was notified. Another resident with severe protein-calorie malnutrition and a g-tube had repeated refused or missing weights, no follow-up documentation for one promised weigh-in, and no evidence the MD was notified of the omitted or refused weights.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A resident with multiple serious cardiac and neurologic conditions experienced a notable change in condition, including lethargy, labored breathing, low oxygen saturation, and hypotension in one arm, requiring initiation of 3L O2 with improvement in SpO2. Nursing documentation reflected these findings but did not include any notification to the physician or the family representative. Subsequent record review and interviews with the APRN, the family representative, and the DON confirmed that the provider and family were not informed of the change in condition and that the family was only contacted after the resident died.
A resident with spinal diagnoses and esophageal obstruction experienced repeated significant weight loss after admission, with weights dropping from 134.4 pounds to 118 pounds, then to 112.4 pounds and 106.2 pounds. The record showed no evidence of re-weighing or timely MD/NP/PA notification after the significant losses, and the resident also refused ordered nutritional supplements for an extended period without evidence the practitioner was notified.
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