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.
A resident with severe cognitive impairment, multiple comorbidities, and identified risk for pressure ulcers developed a new in-house acquired stage 2 pressure ulcer to the buttock. Nursing documentation indicated that family, physician, and wound nurse were notified and wound care was initiated per an unsigned order, but the ADON later acknowledged not notifying the physician and could not identify who gave the wound care order. The attending physician reported not managing wounds or writing the documented order, and the wound care NP stated they first assessed the wound nearly two weeks after its onset and had no prior notification. The wound care schedule initially did not list the resident for wound rounds, and the DON could not explain the omission, demonstrating a failure to promptly notify the physician and secure valid treatment orders for a significant change in condition.
A resident with diabetes and moderate cognitive impairment had a physician order requiring use of a Glucagon kit, provision of a high-carb snack, and physician notification for FSBS <71. One evening, the resident’s FSBS was documented as 64 and 40 units of long-acting insulin were administered, but the physician was not notified as ordered. The next morning, the resident was found unresponsive, EMS was called, and EMS reported the resident’s blood sugar was 41. Staff and leadership later confirmed that facility policy and the medical director’s expectations required physician notification for blood sugars below the specified threshold, which did not occur in this case.
A resident with diabetes and intact cognition had multiple FSBS readings above 350 mg/dL, for which 10 units of Humalog insulin were administered per sliding-scale orders that also required notifying the MD when FSBS was between 350 and 400. Review of progress notes and MAR showed no documentation that the MD was notified for any of these elevated readings. The resident reported their blood sugars had been well controlled prior to admission but had become significantly higher in the facility. An RN confirmed the notification requirement in the insulin order, acknowledged that no MD notification was documented for the elevated FSBS values, and the DON stated staff should notify the physician when orders direct them to do so.
A resident with severe cognitive impairment and diagnoses including obstructive uropathy and non-Alzheimer dementia had physician orders for weekly weights, a milk/soy protein supplement, and sodium bicarbonate. Over multiple occasions, the resident refused the ordered protein supplement, a scheduled weight, and sodium bicarbonate, with these refusals documented in nurses' notes. However, there was no documentation that the resident's family or physician were notified of these refusals, despite facility policy and staff statements indicating that such refusals should be communicated and recorded. The DON confirmed that the record lacked evidence of required notifications.
A resident with severe cognitive impairment, dementia, and total dependence for ADLs had a family member listed as POA, responsible party, and primary emergency contact. A nurse practitioner prescribed sertraline 25 mg daily for mood, and nursing documentation showed the resident continued on the medication without adverse reactions. However, there was no documentation that the resident’s representative was notified of the new medication order, and the DON confirmed the nurse who received the order did not contact the representative.
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