A resident with severe cognitive impairment had new orders for an antibiotic for cellulitis and ivermectin lotion for head lice, but the facility did not document notifying the RP or family about either change. The RP stated she was upset and shocked by the resident's condition, while the DON said the facility expected nurses to notify responsible parties of changes in condition and new physician orders and to document all contact attempts.
Failure to Notify Family Member of Repeated Meal Refusals: A resident with severe cognitive impairment, hospice involvement, and a care plan addressing consistent refusal of meals and fluids repeatedly refused meals over several days, but the facility did not document nursing follow-up or notify the resident's family member. The hospice nurse, MD, and DON all described the resident's frequent refusals, and the family member stated they had not been called about the ongoing meal refusals and would have tried to help the resident eat if informed.
A nurse gave a resident the wrong strength of docusate and did not notify the MD, then failed to complete an ordered IV vancomycin dose after the IV became clogged and could not be reinserted. The resident, who had MRSA and surgical wounds, reported the events and the ADON and DON confirmed there was no documentation that the physician was contacted.
A resident with COPD, acute respiratory failure with hypoxia, sepsis, and other serious diagnoses developed confusion, delusions, pallor, and worsening oxygenation while on O2 and ordered BiPAP. Staff observed the resident was not using BiPAP, was difficult to arouse, and had an O2 sat of 84%, but the RN did not notify the MD immediately and continued monitoring. The MD was not contacted until the resident became minimally responsive with an O2 sat of 80%, after which the resident was transferred to the hospital, admitted to ICU with respiratory distress and hypotension, and later died after CPR was stopped at the daughter’s request.
Failure to notify a resident representative of a behavioral incident. A resident with dementia, epilepsy, and severe cognitive impairment hit another resident, and the LPN separated and assessed both residents with no injuries noted. The chart had no documentation that the resident’s family member was informed, and the DON and ADM later stated they were unaware the family had not been called. The family member said she only learned of the incident when contacted later and was upset no one had notified her sooner.
A resident with a femur fracture, CKD-related anemia, and a cognitive communication deficit fell out of bed and was found on the floor by the ADON. The physician and DON were notified promptly, but the resident’s responsible party/MPoA was not notified until later that day, despite staff stating family notification should occur immediately after a fall. The ADON documented the late notification, while the responsible party reported being told about the fall much later than expected.
A resident with bipolar disorder and schizophrenia was started on risperidone after a psych hospitalization, but the facility did not notify the resident’s representative when the medication was initiated or later resumed. The record showed the resident signed the consent form herself, while the POA/RP said she was not informed and never signed consent. The MD, DON, and Administrator acknowledged that consent and notification were required for this psychoactive medication.
A resident with severe cognitive impairment, chronic pain, OA, fibromyalgia, osteoporosis, and prior CVA was lowered to the floor during a transfer from a shower chair. Although staff initially documented no injury or pain, the resident later showed escalating right knee pain, received PRN APAP, and was eventually found to have an acute nondisplaced fracture on x-ray before being sent to the ER. Staff interviews and records showed the MD/NP was not notified promptly when the resident first began showing pain and change in condition after the fall.
A resident with hepatic encephalopathy and CKD stage 4 missed multiple ordered doses of rifaximin 550 mg because the medication was unavailable, and the MAR showed the doses as pending delivery, pending pharmacy, or no supply. The record had no documentation that the physician or RP was notified, and interviews confirmed the RP was not informed until later and the LVN did not notify the physician or RP when the medication ran out.
The facility failed to consult the physician when two residents consumed alcohol at a fiesta event without doctor’s orders. The DOR allowed the drinks at his discretion, the DON said staff were unaware alcohol would be served, and the EMR showed no physician contact. One resident had moderate cognitive impairment and the other had intact cognition; both were their own RP, and outside providers confirmed they were not notified.
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