Failure to Notify Physician of Significant Change in Resident Condition
Summary
The deficiency involves the facility’s failure to consult with a resident’s physician when there was a significant change in the resident’s physical, mental, or psychosocial status. The resident was an adult male with multiple serious diagnoses, including Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a doctor. On one day, his blood pressure readings taken by a medication aide were 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., which were hypotensive. There was no documentation that a Change in Condition (CIC) assessment was completed that day, and no progress notes indicated that the physician had been notified of these low blood pressure readings or of any change in condition. Staff interviews and records showed that the resident’s condition had changed over the same period without appropriate escalation to a provider. CNAs reported that the resident, who was normally alert, communicative, and active on his computer, slept most of the day and night, was very sleepy, did not eat breakfast or lunch except for one cup of pudding, and had minimal verbal communication, sometimes only nodding his head with eyes closed and heavy breathing. A CNA stated he informed the floor nurse that the resident had not eaten and was very sleepy but could not recall the nurse’s name or what action was taken. A medication aide stated he held the resident’s blood pressure medication due to low blood pressure and told an unidentified nurse, but he could not say which nurse or what the nurse’s response was. The nurses who worked those shifts stated they were not informed of the low blood pressure readings or the resident’s poor intake and increased sleepiness. The following morning, an LVN entering the resident’s room found him drowsy, barely speaking, with an untouched breakfast tray, clammy to the touch, and with a low blood pressure of 75/54. The LVN documented that the resident was unresponsive to a sternal rub and was sent out due to an acute change in condition, hypotension, increased work of breathing, and unresponsiveness; EMS, the provider, the DON, and family were notified at that time. Subsequent hospital information obtained by surveyors indicated the resident was admitted to ICU for unresponsiveness, required multiple rounds of CPR after his heart stopped, and was diagnosed with a blood infection, septic shock, mucus in his lungs, and an acute stroke, with a blood sugar of 63. The resident’s primary medical doctor reported that when he saw the resident at the hospital, the resident had vomit around his mouth, appeared to have been deteriorating for hours, and had technically passed away twice but was resuscitated. The facility’s DON confirmed that per policy, providers should be informed of all significant changes, and that CNAs and medication aides were expected to report changes to nurses, who in turn were to notify the provider and document the change in condition, which did not occur in this case. An Immediate Jeopardy was identified related to this failure to notify the physician of the significant change in condition.
Removal Plan
- Removed medication aide #1 from assignment pending completion of in-service training on Medication Administration, reporting abnormal vital signs to charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action for failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process: evaluation/assessment, documentation (vital signs and Change in Condition assessment/progress note), reporting to the medical provider, notification of resident representative, and ensuring all steps are documented in the EHR.
- Required licensed nurses to review medication aide vital sign forms to identify abnormal vital signs, re-assess residents, implement interventions, notify the medical provider and resident representative, and document actions in the EHR.
- Required nurses to report identified/suspected changes in condition to the oncoming nurse during shift handoff to ensure continuity of reporting.
- Prohibited any nursing staff (full-time, part-time, PRN, or on leave) from working their next assigned shift until all required in-service training was completed.
- Educated all certified medication aides on medication administration (rights of medication administration) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process for subtle changes in condition and expectations for use.
- Required Stop and Watch forms to be completed in the EHR and/or on paper, communicated to the nurse, and paper forms turned in to the charge nurse for nurse follow-up assessment and notifications.
- Required nurses to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the DON when a change in condition is identified and Stop and Watch is completed, including confirmation that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse's station.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for state surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication, orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all PRN/on-leave nursing staff are in-serviced prior to working their next shift and that administrative nursing staff provide in-service/education prior to staff working.
- Ensured all residents receive appropriate care after a change in condition.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F580 and the plan of removal to lift immediate jeopardy.
- Required certified medication aides to handwrite all vital signs on the designated vital sign form/log and turn it in to the charge nurse.
- Placed a copy of the medication aide vital sign form/log in the Abatement/Plan of Removal binder for state surveyor review.
- Ensured Stop and Watch forms were available in designated locations for staff access and use.
- Required DON notification by phone when a Stop and Watch form is completed and a change in condition is identified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Timely Notify Physician for Worsening Cough: A resident with CHF, edema, and other cardiac diagnoses developed a persistent worsening cough with SOB and severe discomfort after being placed on comfort care and do-not-hospitalize orders. Staff gave PRN morphine and cough syrup with little relief, but the RN and DON knew about the decline and relied on faxing the MD rather than timely direct notification. The care plan did not reflect the comfort care orders or guidance for managing a change in condition.
A resident with severe cognitive impairment, diabetes, and an existing heel PI developed a new ischemic/necrotic change to the right first toe, but the facility did not notify the PCP or wound care provider as ordered. The toe change was documented on a skin audit and later observed as black on the top of the toe, yet the wound team was not updated and the wound later measured larger than when first identified.
The facility failed to notify the provider of a significant orthostatic BP drop for one resident and failed to notify the provider after two blood glucose readings over 400 mg/dL for another resident. One resident had intact cognition, antipsychotic use, and an order for monthly orthostatic BP checks, but the EMR showed a systolic drop from lying to standing without provider notification. Another resident with type 1 DM and severe cognitive impairment had orders to update the provider for BG >400 mg/dL, yet EMR review showed readings of 498 mg/dL and 449 mg/dL with no documented provider notification.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
A resident with moderate cognitive impairment and multiple chronic conditions sustained a skin tear to the lower shin that was documented by an LVN, who attempted but failed to reach the resident’s POA and did not leave a voicemail, assuming the treatment nurse would notify the family. The treatment nurse documented the wound, obtained MD orders, and provided treatment but did not contact the family, citing a facility practice that charge nurses handle family notification. The resident’s representative reported learning of the injury only upon visiting and seeing the wound, and leadership acknowledged that both the physician and the representative were not notified as required by the facility’s significant change in condition policy.
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.
Failure to Timely Notify Physician for Worsening Cough
Penalty
Summary
The facility failed to timely notify the physician when a resident with intact cognition and diagnoses including edema, heart failure, hypertension, premature ventricular contractions, and tricuspid regurgitation developed a worsening cough that did not improve. The resident’s quarterly MDS showed she required moderate assistance with transfers, dressing, and hygiene. After a clinic visit, she returned with orders for comfort care only, including do not hospitalize, stopping metolazone, increasing Lasix to 80 mg twice daily, and discontinuing labs per family request. The physician’s note described chronic fluid retention, weight gain, generalized edema, decreased strength, occasional shortness of breath, and a persistent cough, with the family choosing comfort care after discussion of prognosis and limited benefit of further hospitalization. Nursing notes showed the resident continued to cough chronically and was not resting well. Staff administered PRN morphine in an attempt to relieve discomfort from the cough related to fluid overload, but the medication was ineffective and the resident reported severe pain rated 8 out of 10 with no relief from the cough or discomfort. The care plan addressed diuretic therapy and monitoring for side effects, but it did not include the comfort care orders, the do not hospitalize direction, discontinuation of labs, or instructions for maintaining comfort if the resident’s condition changed. Interviews with the RN and DON confirmed they were aware of the resident’s coughing and believed it was related to fluid retention. The DON stated the facility had received the order not to send the resident to the hospital and agreed the care plan should have included comfort measures. The record also showed staff faxed the physician for guidance but did not receive a response, and the DON stated they could not call the doctor during clinic hours and had been advised to fax instead. The physician was not contacted until the on-call MD later ordered increased PRN morphine frequency for pain, shortness of breath, or cough.
Failure to Notify PCP of New Toe Skin Alteration
Penalty
Summary
The facility failed to ensure the PCP and wound care provider were notified of a change in condition for a resident with severely impaired cognition, diabetes mellitus, and non-Alzheimer's dementia who was dependent on staff for toileting, bed mobility, transfers, and lower body dressing. The resident was admitted with an unstageable pressure injury to the left heel and had a care plan focused on that wound, but the care plan did not include any toe concerns. A weekly skin audit later identified ischemic tissue on the tip of the right first toe, measuring 1.2 cm by 0.9 cm, and a nursing progress note documented that an on-call senior care NP was notified and instructed staff to continue monitoring and update the PCP wound nurse on the next business day. The required update was not completed. The consultant wound care NP visit on 4/16/26 documented the left heel wound as healed and noted no new skin issues were reported, and the NP was not informed about the new right first toe skin alteration first observed on 4/4/26. When the wound provider later evaluated the toe, it was documented as a non-pressure wound of unknown duration, full thickness, and at least greater than 14 days old, with measurements of 1.2 cm by 1.8 cm. The wound had increased in width by 0.9 cm since it was first measured, and new orders were issued for Betadine and off-loading. During observation, the resident's right first toe was exposed and black on the top, and staff described it as a bruise of unknown duration. Interviews confirmed the facility did not complete the ordered update to the PCP wound care provider and did not maintain consistent monitoring of the necrotic toe. The DON stated the facility should have updated the PCP or wound provider as identified in the on-call order and documented the change in the medical record, and the wound care NP's medical liaison confirmed their service was not updated on the new skin alteration.
Failure to Notify Provider of Orthostatic BP Drop and Critical Hyperglycemia
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with orthostatic hypotension. R5’s quarterly MDS showed intact cognition, antipsychotic use, and substantial to maximum assistance with ADLs. R5 had an order for monthly orthostatic blood pressure monitoring because of antipsychotic use, and the 4/18/26 vital signs record showed a blood pressure of 122/72 lying, 118/71 sitting, and 101/62 standing, reflecting a systolic drop greater than 20 mmHg from lying to standing. The EMR did not show that the physician was notified of this orthostatic blood pressure drop. During interviews, RN-D and RN-C stated staff should notify the provider for a 20-point orthostatic drop, and RN-C stated the 4/18/26 drop had not been reported. The facility also failed to notify the physician after two hyperglycemic blood glucose readings greater than 400 mg/dL for another resident. R68’s quarterly MDS showed severely impaired cognition and substantial to maximum assistance with ADLs, and diagnoses included type 1 diabetes mellitus with other diabetic neurological complications and other frontotemporal neurocognitive disorder. R68 had an order for accuchecks three times daily with meals and to update the provider if blood sugar was less than 90 mg/dL or greater than 400 mg/dL. The EMR showed blood glucose readings of 498.0 mg/dL on 3/26/26 and 449.0 mg/dL on 4/20/26, but there was no evidence the provider was notified for either reading. RN-B and RN-A stated staff should notify the provider for elevated blood sugar readings over 400 mg/dL, and RN-A could not locate documentation of provider notification for the two events.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition following a skin tear. The resident was an older male with anxiety disorder, hypertension, and benign prostatic hyperplasia, admitted with a care plan that included treatment for a skin tear to the left lateral shin. An admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Facility incident and accident reports identified a skin tear event for this resident, and physician telephone orders were obtained to cleanse the affected area and apply dressings daily. A progress note documented that an LVN observed a skin tear/abrasion to the left lower shin and attempted to call the resident’s daughter/POA, but there was no answer and no voicemail left. The treatment nurse’s subsequent progress note documented that she was notified of the skin tear and that the wound measured 8x6 cm, and she obtained and implemented MD orders, but did not contact the family, stating that per facility culture the charge nurse was responsible for family notification. The resident’s representative reported she was never contacted by nursing staff and only learned of the skin tear when she visited and saw the injury. Interviews with LVN A confirmed she attempted to call but did not leave a voicemail and believed the treatment nurse would call the family, while the treatment nurse confirmed she did not contact the family. The DON acknowledged that the resident’s representative should have been notified per the facility’s significant change in condition policy, which states that the resident representative will be notified of a change in condition. The Administrator stated that the physician should have been notified but was not, while staff prioritized providing care to the resident at that time.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
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