Failure to notify the MD and resident representative of a significant BiPAP setting change. A resident with CHF, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema had a physician order for BiPAP 28/5 with FiO2 40%. The RT changed the settings to 25/5 because the machine could not tolerate higher settings, but did not notify the MD, nursing supervisor, or representative, and did not document the change.
A resident with osteonecrosis, a buttock furuncle, and CHF had scheduled tramadol discontinued and then restarted as PRN for pain, but there was no documented notification to the resident or the resident’s representative. The resident was cognitively intact and reported significant pain, while staff were unsure why the medication changed and acknowledged that residents or families should be informed when pain meds are changed.
A resident with severe neurologic impairment, trach dependence, and a feeding tube returned from the hospital with moisture associated skin damage to the sacral area that later became an unstageable wound. The resident’s representative was not promptly notified of the change in status, and the record lacked documentation that the family was informed of the new skin breakdown.
Failure to Notify Representative of Medication Discontinuation: A resident with Alzheimer's disease, dementia, depression, and severe cognitive impairment had Namenda and Midodrine discontinued, but the chart contained no evidence that the resident's representative was promptly notified. Records showed Namenda was stopped for low benefit and polypharmacy, while staff interviews confirmed the family was not informed and later discovered the missing meds during a care plan meeting.
Failure to notify designated representative of new antibiotic treatment: A resident with severe cognitive impairment, CKD, HTN, and chronic lung disease developed a cough, was started on amoxicillin-clavulanate for the change in condition, and received the antibiotic as ordered. However, the resident’s designated representative was not documented as being notified of the new treatment until several days later, despite facility policy requiring timely notification of the family or health care agent.
Failure to notify the resident representative before a room change. A resident with vascular dementia, encephalopathy, and severe cognitive impairment was moved to another unit, but the family was not given prior notice or the new room number. Staff interviews confirmed that the transfer occurred before Social Services was aware of it, despite the facility’s usual process of contacting families before room changes.
A facility failed to notify and involve a resident’s representative in a significant Seroquel dose reduction. The resident had Alzheimer’s disease, psychotic disorder, depression, anxiety, and severe cognitive impairment, and the antipsychotic was tapered after a psych consult and provider review. The facility could not produce documentation showing the representative was informed or consulted before the med change, and interviews confirmed the representative was not notified.
Failure to notify a resident representative after a fall with injury. A resident with severe cognitive impairment and diagnoses including stroke, lung CA, and brain CA fell and sustained a small eyebrow laceration. The RN documented that no emergency contact info was available and that SW would follow up, but the record had no proof of notification or attempts. The representative said they were never informed, and staff interviews showed confusion about who was responsible for making the contact.
Failure to Notify MD of Acute Decline and Dysphagia An LPN and RN documented that a resident with Parkinson’s disease and dementia became non-arousable, could not swallow food or oral meds, and showed groaning and facial grimacing with care. The resident’s family was contacted about possible end-of-life care, but the MD was not notified of the resident’s inability to take PO intake or pain meds for over 24 hours. The resident was later sent to the hospital for IV fluids and was diagnosed with sepsis.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
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