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 CAD, DM, morbid obesity, and debility was not told before taking an LOA that it would end his Medicare Part A coverage. After the resident returned, the MDS nurse issued a NOMNC and therapy services ended because he no longer qualified for skilled coverage. The DRS said he learned of the discharge after the LOA had already occurred, and the resident stated he had only been given medication instructions and meds for the trip, not notice that the LOA would affect coverage.
A resident with moderate cognitive impairment and an activated POA had repeated refusals of care and treatment, including labs, weights, bowel meds, and other treatments, but the facility did not document notifying the POA. The care plan and orders lacked direction for staff on when to notify the provider or POA about refusals, and there was also no documentation that the POA was notified before the resident went to the ER after a fall.
A resident with chronic hepatic failure and alcoholic cirrhosis was ordered Lactulose three times daily for bowel management, but the MAR showed that only a small fraction of ordered doses were administered over a month and that multiple subsequent doses were refused. Despite a provider notification form noting ongoing refusals and staff interviews acknowledging frequent medication refusals, there was no documentation in progress notes that the physician was notified of the repeated Lactulose refusals, and the physician’s visit note did not address them. Staff demonstrated limited understanding of the purpose of Lactulose and monitoring needs, the care plan lacked specific interventions for hepatic failure/cirrhosis beyond bowel management, and the DON was unaware of current documentation practices, contrary to the facility’s Notification of Changes policy requiring prompt physician consultation.
A resident with intact cognition and a care plan noting risk for infection due to urinary incontinence developed new hallucinations, severe pain, vomiting, diarrhea, fatigue, refusal of medications, poor intake, and repeated fevers with tachycardia over several days. Despite abnormal vital signs and documented behavioral and neurological changes, staff did not notify the attending MD as required by facility policy and the care plan directive to update the provider as needed. The resident’s condition worsened until she appeared ill, shivering, pale with a grey hue, and reporting pain all over, prompting transfer by ambulance to the ED, where she was diagnosed with sepsis due to E. coli, UTI from an obstructing ureteral stone, acute kidney injury, and septic shock. The attending MD later confirmed she had not been informed of the change in condition and stated she should have been contacted when the resident developed a fever.
A resident with chronic lung disease and intact cognition experienced an acute hypoxic episode during PT/OT, with documented respiratory distress, fluctuating O2 saturations, and cyanotic lips, leading nursing staff to place the resident on CPAP. Facility records lacked documentation that the provider or family were notified of this change in condition, despite the resident later reporting an O2 saturation of 66% and a family member being told it was 89% when rechecked. In interviews, an LPN, RN, risk management staff, NP, and DON all acknowledged that such low O2 levels represented a change in condition that should have been documented and reported, and the facility’s Notification of Changes policy required informing the resident/representative and the physician of such changes.
A resident with multiple serious diagnoses, including CHF, CKD, Afib, and a history of syncope, experienced a brief syncopal episode during a transfer when a TMA assisted the resident to stand with a gait belt. The resident went limp, was lowered back into a recliner, then became alert and responsive, and nursing staff, including two LPNs and an RN manager, responded. Although staff acknowledged this was a change in condition that required documentation and provider notification, one LPN did not obtain vital signs, did not notify the provider, and did not write a nursing note, and there was no documentation that the physician was notified at the time of the event. The DON and the MD both later stated the provider should have been notified immediately, and the facility’s change of condition policy required physician notification for status changes.
A resident admitted after a CVA with documented hypokalemia was discharged from the hospital on potassium chloride 10 mEq BID, with an e-prescription confirmed by the pharmacy and potassium tablets delivered to the facility. The potassium order was not entered on the EMAR at admission, and the resident missed multiple potassium doses over several days. Staff observed that the potassium card was untouched and that the medication was not on the EMAR, but the medication was set aside and no provider notification occurred at that time. Interviews with nursing staff, the DON, and the MD confirmed that the physician was not informed of the omissions or the low potassium level, despite facility policy requiring timely physician notification when treatment or medications are altered significantly. This failure to notify the physician of omitted potassium doses constituted the cited deficiency.
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