Failure to Notify POA and Providers of Significant Changes in Condition
Summary
The deficiency involves the facility’s failure to notify resident representatives and providers of significant changes in condition for two residents. For one resident with traumatic hemorrhage of the right cerebrum, carotid artery aneurysm, convulsions, and a cognitive communication deficit, the face sheet and POA documents identified the spouse as POA and first emergency contact, and the son as second emergency contact and secondary POA. Social services documentation and nursing notes showed that this resident explicitly stated that her husband should be the first person notified of any changes in condition and her son the second. Despite this, multiple SBAR forms documented repeated changes in condition, including abnormal vital signs with unresponsiveness, new swallowing issues, a positive COVID test, swallowing difficulties, a fall with head injury, an altercation with another resident, a seizure, and another fall. In each of these events, staff notified only the resident’s daughter‑in‑law, identified as the resident representative, and did not notify the husband or son as emergency contacts/POA. Interviews further confirmed the pattern of non‑notification of the appropriate decision‑makers for this resident. The son reported that the facility did not notify him after any of the resident’s changes in condition and that he learned of these events from the resident representative instead. The husband/POA stated he did not recall being notified by the facility regarding any of the changes in condition and did not know who the facility contacted. The resident representative stated that staff began contacting her instead of the husband and son, sometimes because they did not answer the phone, and acknowledged that this practice bothered the son. The Unit Manager stated that facility nursing staff were required to call the POA and emergency contact for any change in condition and that if a family member onsite was not the POA, staff should still notify the POA. She acknowledged that nursing staff should have contacted the resident’s husband or son regarding the changes in condition, even when the resident representative was present in the facility. For the second resident, who had dementia with behavioral disturbance, chronic respiratory failure with hypoxia, chronic CHF, and hypoglycemia, and who was documented as full code with all interventions, the facility failed to notify a provider when the resident exhibited an acute change in condition. Nursing progress notes documented that in the early morning hours, the resident was mouth breathing with gurgling sounds in the deep throat, had non‑productive coughing, an oxygen saturation of 92% on 3 liters of oxygen, and was uneasily aroused by tactile/verbal stimuli, with abnormal lung sounds including bilateral upper lobe rhonchi and diminished lower lobe sounds. The nurse recorded that the primary care physician was made aware via a non‑emergent in‑house communication log for further evaluation and treatment, and that the oncoming nurse would be informed. Later that morning, the nurse was called to the resident’s room and found the resident unresponsive, with CPR initiated and a code blue performed by EMS, and the resident was pronounced dead. Additional interviews and documentation clarified that the nurse practitioner considered the information placed in the non‑emergent provider logbook inappropriate for that communication channel and stated that staff should have called a facility provider and 911 immediately regarding the resident’s status, rather than using the non‑emergent log. The DON stated that the first time she was made aware of the situation was when the code blue was called and that staff were required to notify a provider for any change in condition; review of the on‑call provider log showed no calls for this resident on the relevant dates. A CNA reported that when she arrived, the resident was not responding or opening her eyes, was coughing with gurgling sounds, and appeared very pale, and that she and another CNA could not obtain a pulse before summoning the nurse and initiating the code blue. The nurse who cared for the resident that morning stated she obtained but did not document vital signs, recalled an oxygen saturation of 88% on 2 liters improved to 92% on 3 liters, noted coughing with inability to expel mucus, and believed the resident was at baseline, so she did not call the on‑call provider and instead wrote in the non‑emergent log. The oncoming nurse stated she was told the resident was not awake or alert enough to receive morning medications, did not see the resident until notified by the CNA that the resident was not breathing, and stated that if a sternal rub was necessary, the nurse performing it should have called the provider. These actions and inactions led surveyors to identify an Immediate Jeopardy related to failure to notify providers and representatives of changes in condition.
Removal Plan
- Provide change in condition (CIC) education to LPN and RN staff, including definition of CIC, appropriate communication to providers, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention.
- Ensure all nurses on duty since the event receive the CIC education and understand their responsibility (DON/designee verification).
- Conduct an initial review of the non-emergent provider communication log process with the provider and administration team to clarify appropriate acuity of notifications.
- Require that changes of condition be reported directly to the provider; restrict the non-emergent log to non-emergent patient requests or medication refills.
- Update the non-emergent provider communication log form to reflect the revised process.
- Place the agency nurse who documented the progress note on administrative leave pending review of care.
- Conduct an in-person meeting with the agency nurse by two nurse managers to review documentation and provide one-on-one education regarding substandard care.
- Notify the agency of the event and investigation involving the agency nurse.
- Assess and document vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) on every resident in the facility.
- Have nurse managers conduct room-to-room visual inspections to verify proof of life and resident stability.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
