A resident with vascular dementia and severe cognitive impairment, admitted for a short hospice respite stay, was discharged from the facility by his daughter without documented verification of her authority or notification and agreement from his listed emergency contact, his spouse. Staff, including an LPN and an RN, relied on the daughter’s statements that the resident’s wife wanted him home and did not independently contact the spouse, and facility records lacked documentation of any attempt to notify the responsible party or confirm consent before the resident left.
Two residents experienced significant changes in condition without timely notification to their representatives and, in one case, the physician. One cognitively impaired resident with multiple serious diagnoses suffered a cardiac arrest; staff initiated CPR, called 911, and transferred her to the hospital, but documentation showed only the resident herself was listed as notified, and her healthcare proxy later reported she was never contacted by the facility and learned of the event from the hospital. Another cognitively intact respite resident developed skin tears to the arm and leg, reportedly related to an outing incident, which were documented on CNA task lists but not reflected in nursing progress notes or the discharge summary; his daughter discovered a bandage at pickup and stated she was never informed of the incident or injuries despite attempts to reach facility leadership. The DON acknowledged that a change in condition should have been documented and that the nurse, MD, and family should have been notified, contrary to the facility’s own change-in-condition policy.
Surveyors found that staff failed to notify representatives for two residents who experienced significant changes in condition and were transferred to the hospital, despite a policy requiring such notification unless the resident specifically declines it. Record reviews showed documentation only that the residents themselves were notified, with no record of representative contact or refusal of notification. One family member reported not being informed of lab results, tests, changes in condition, or the hospitalization, learning of the situation only from the hospital after the resident was in the ICU. Staff interviews revealed uncertainty about who is responsible for notifying representatives, and leadership reported they were not aware that policy required representative notification for changes in status and hospital transfers.
The facility failed to notify representatives and physicians of significant weight loss in two residents, despite a policy requiring prompt communication of changes in condition and completion of an SBER change-in-condition evaluation. One resident with multiple chronic conditions, including dementia and diabetes, experienced more than a 12% weight loss over several months without documented notification to the representative or physician, and the representative reported not being informed of the weight loss or related interventions. Another resident with extensive cardiovascular, neurologic, and psychiatric diagnoses, including CHF, vascular dementia, and mild protein-calorie malnutrition, also lost more than 12% of body weight over six months, with no documented family or physician notification. An LPN acknowledged that the physician and representative had not been contacted, the RD stated that notification was a nursing responsibility, and the DON confirmed the absence of documentation of required notifications.
A resident with type 2 DM on sliding-scale insulin had numerous blood sugar readings above the ordered notification threshold over several months, yet there was no documentation that the physician was notified as required. The MAR showed repeated BSLs greater than 400 mg/dL, while the insulin order directed staff to notify the MD for values above this level. In interview, the DON acknowledged that nurses should have notified and documented physician contact for these out-of-parameter results, and that the existing orders still required notification despite an increase in the sliding scale range, contrary to the facility’s own notification-of-change policy.
A resident with type 2 DM, foot ulcers, and cognitive impairment had physician orders for HumaLOG sliding‑scale insulin before meals and at bedtime and Lantus insulin at bedtime. Over two consecutive months, the MAR showed multiple instances where blood glucose checks were not completed as ordered and numerous refusals of Lantus were documented, yet there was no documentation that the resident’s representative was notified of these refusals or missed monitoring. The resident’s representative later reported not being informed of the non‑compliance, an LPN acknowledged not notifying the family in this case, and the DON stated that the expectation per facility policy was to notify and document when residents refuse medications or treatments, including clinical complications requiring notification.
A resident with dementia and a court determination of total incapacity had documented upper dentures and a court-appointed legal guardian whose contact information was on file. The resident’s record indicated use of dentures or partials, yet the resident was later observed in the dining room without dentures, and staff believed the dentures had been missing for several weeks. The legal guardian reported not being informed that the dentures were missing, and the ED acknowledged the guardian was not notified because dentures often go missing and later reappear, despite a facility policy requiring notification of the resident’s representative when an incapacitated resident experiences changes requiring decisions.
A resident with multiple comorbidities and a history of falls, but cognitively intact, experienced two falls on the same day. For the first fall, staff documented vital signs and provider notification but did not document any notification to the resident’s family, despite facility policy requiring representative notification after accidents. For the second, unwitnessed fall, the resident was found on the floor with a head wound and slight ankle pain; staff documented leaving messages for the NP on call and the resident’s husband and recorded vital signs, but there was no documentation of a provider call-back or follow-up after the head injury, and the exact time of the fall was not recorded. The DON confirmed these documentation and notification failures and acknowledged that neurological checks were expected after the first fall.
A resident with a history of digestive surgery and cardiac/vascular procedures reported feeling unwell with ongoing bowel movements and later was found hunched over on the toilet, prompting an LPN to call a Code Blue and 911, resulting in transfer to the hospital. A Change in Condition assessment documented unresponsiveness, and a Transfer Assessment was initiated, but both lacked documentation that the resident’s representative was notified, despite facility policy requiring prompt notification and documentation for significant changes and transfers. The DON later learned from the hospital that the representative had been contacted by the hospital during the night, and the LPN Unit Manager stated she informed the representative the next morning but did not document this communication in the medical record.
A resident's representative was not promptly notified after the resident sustained a fall. Documentation showed missing contact information, and interviews confirmed that the family only learned of the incident after observing injuries during a visit and contacting the unit manager. Facility policy requires immediate notification of such events, but this was not carried out.
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