Failure to Immediately Notify Physician and Family of New Pressure Ulcer: A resident with intact cognition, diabetes, and incomplete quadriplegia developed a stage 3 sacral pressure ulcer that an RN noticed on the evening shift. The RN told the resident about the sore but did not notify the MD or family, and the family member reported she was not informed until she visited the next day. Facility records showed the wound was later assessed by the WCN, the MD/NP was notified, and the resident was transferred to the hospital for a change in condition.
A resident with severe cognitive impairment, CHF, and renal disease showed clear signs of decline, including poor intake, lethargy, flushed/clammy skin, weakness, and reduced responsiveness, but the assigned LPNs did not immediately notify the MD or document assessments. The resident later developed respiratory distress with abnormal vital signs and was sent to the ER, where he died; the physician said he was only contacted after the resident had already passed away.
A resident with dementia, weakness, and high fall risk had repeated falls during transfers while staff used improper transfer techniques and, in several instances, no gait belt. The resident cried and reported pain after some of the falls, but the physician, hospice physician, and NP were not consistently notified of the incidents. Interviews and video showed staff confusion about the resident’s transfer status and repeated transfers without the required assistance.
Failure to notify physician and family of x-ray result and change in condition: A resident with dementia and multiple chronic conditions had a chest x-ray after respiratory decline, and the NP/MD ordered treatment after the result showed bronchitis. The LPN did not document or recall notifying the resident’s responsible parties of the result, and both responsible parties said they were not informed until the resident later worsened and was transferred to the hospital with aspiration pneumonia.
Physician Not Notified When Scheduled Insulin Was Held: A resident with DM and acute kidney failure had scheduled Tresiba insulin held for three consecutive doses because blood sugars were within normal limits, but the MAR and nurse's notes showed no documentation that the MD/NP was notified. The DON stated staff were expected to notify the physician when meds were held three times in a row, and an LVN said she should have called the provider for possible med adjustments.
Failure to Notify Physician of Missed Medications: A resident with multiple chronic conditions, including HTN and a recent fracture, missed multiple doses of Enoxaparin and lisinopril-hydrochlorothiazide because the meds were unavailable. The MAR and progress notes showed the doses were not given, but there was no documentation that the MD or NP was notified, and the physician confirmed he was not informed about the missed Enoxaparin doses.
A resident with acute kidney failure, gallbladder disease, altered mental status, and a cognitive communication deficit was started on a new IV vancomycin order for leukocytosis, but the resident’s legal representative and family were not notified. The chart had no note of family contact, and interviews with the family, legal representative, ADON, DON, NP, and RN showed the family was told they had been notified when they had not been. The facility’s policy required timely notification of the resident, family/legal representative, and physician for significant changes in treatment.
A resident with severe cognitive impairment, cerebral palsy, psoriasis, seborrheic dermatitis, and diabetes developed scratches and dried blood on the face and arm after staff observed no marks earlier in the shift. An LVN assessed the resident, cleaned the wounds, and assumed the resident scratched herself, but did not notify the MD or resident representative; a second LVN also did not make notifications after receiving report. The DON later learned of the incident during the morning meeting.
A resident with severe cognitive impairment and a history of acute MI had an unwitnessed fall with bruising to the face and hand, but the incident was not immediately reported to the Administrator, DON, physician, or RP. Staff said they notified the weekend supervisor, while the DON later learned of the fall days afterward when bruising was seen. The NP stated he should have been contacted the day of the fall and would have recommended hospital transfer that day.
A resident with dementia, diabetes, a history of falls, and impaired balance had an unwitnessed fall found by CNAs with no injury or pain noted, but the event was not documented in the nursing notes, incident log, assessment record, or EMR, and the MD was not notified. Staff interviews confirmed the fall occurred and that the LPN assessed the resident and returned her to bed, while the DON stated all falls had to be reported to the physician.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.