Facility failed to notify a resident’s family after a fall that caused a large bruise and a laceration over the right eye. The resident was admitted for therapy services, and the family later reported they discovered the injury during a visit and had not been told about the fall. The ADON and clinical VP agreed the family should have been notified immediately when the incident occurred.
Failure to notify the physician when a resident’s scheduled hydroxyzine was repeatedly not administered before dialysis. The resident had ESRD and dialysis dependence, and the order directed hydroxyzine before dialysis on dialysis days. MAR review showed multiple missed doses over several months because the resident was out of the facility, while staff said the overnight shift was responsible for giving the medication before the resident left and that recurring missed doses should have been communicated.
The facility failed to notify the physician when a resident’s Lasix was unavailable for administration. The resident had systolic CHF and an order for Lasix 20 mg daily, but the MAR showed repeated charting that the medication was not given because it was not available. Staff stated the nurse should notify the physician when a med is unavailable, yet the LPN was unaware the med was missing and the physician stated he had not been notified.
The facility failed to notify a resident's family member about a UTI and a new antibiotic order for a resident. The record did not document the notification, and both an LPN and the ADON stated the family member should have been informed and the change documented in the medical record.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
Failure to notify resident representatives of significant changes in condition. Two residents had major events, including CPR with EMS transfer and a fall with injuries and hospital transfer, but the facility had no documentation that family or next of kin were notified at the time. The DON stated staff were to notify the physician and family, but the family for one resident was not reached until later when they came to the facility.
A resident with multiple serious medical conditions, including acute kidney injury, sepsis, and diabetes, experienced repeated episodes of abnormal vital signs such as very low blood pressure, low oxygen saturation, and bradycardia. On more than one occasion, there was no documentation that the physician or NP was notified of these changes, nor that the NP evaluated the resident, despite facility policy requiring notification for significant changes in condition. The resident’s family reported they were not informed by the facility about the resident’s deteriorating condition and instead learned of it from the emergency room. The resident was later found unresponsive, transferred to the ER in critical condition, returned while actively dying, and subsequently died, with the death certificate citing protein calorie malnutrition, cognitive impairment disorder, acute kidney failure, and diabetes mellitus as contributing conditions.
The facility failed to notify the physician when a resident repeatedly refused ordered ipratropium-albuterol breathing treatments and reported shaking, shakiness, and weakness with use. The resident had COPD and cough, and staff documented multiple refusals over the month, but there was no documentation that the physician was informed. An LPN knew the resident was getting shaky but did not notify the physician, and both the physician and DON stated they could not locate documentation of notification.
A resident with a history of alcohol abuse, cannabis use, stimulant dependence, and other psychoactive substance abuse, and who was cognitively intact, was found in possession of suspected illicit drug paraphernalia after housekeeping observed a small glass pipe with residue and notified the administrator. The administrator met with the resident, revoked self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and disposed of the pipe, while nursing documentation noted continued illicit substance use and reports of providing substances to other residents. Despite a facility policy requiring prompt physician notification and documentation when changes may require physician intervention, the physician/medical director was not notified and there was no documentation of any physician notification related to the incident.
The facility failed to notify the physician of significant weight loss for a resident admitted with a hip fracture and parkinsonism. The resident lost 18.34% of body weight from admission, and although a dietitian note identified the significant loss and directed staff to alert the physician, the chart showed no physician notification. CMA staff stated the weight loss was overlooked, and the DON confirmed the physician had not been notified.
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