A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO twice daily, but over several days eight doses were not administered because the medication was unavailable or awaiting pharmacy delivery. Multiple nurses documented the missed doses on the MAR yet did not notify the physician, with some stating they did not think or realize notification was necessary. The DON stated she expected staff to notify the provider when medications are unavailable, and the physician reported being unaware of the missed doses and stated that medications should be administered as ordered and that the provider should be notified if a medication is not available.
A resident with dementia, failure to thrive, a fall history, and HTN was found on the floor by an RN, who assessed for pain and injury but did not notify the NP, responsible party, DON, or Medical Director of the fall and entered the event in the EMR as an injury rather than a fall. Two days later, the resident reported new right knee pain and swelling; the NP and family were informed only of the pain, not the prior fall, and an x-ray was ordered. Over the following days, the resident continued to report pain, received multiple analgesics, and underwent imaging, culminating in a CT that showed multiple right hip and pelvic fractures. The NP, Medical Director, and resident representative all reported they were not made aware of the fall until after the CT results and subsequent internal review, and hospital records later documented admission for a displaced right acetabular fracture and severe pain with functional decline after a fall at the facility.
A resident with a history of stroke, dementia, atrial fibrillation, dysphagia, and multiple other conditions was admitted on multiple oral meds, including an anticoagulant. One day after admission, staff documented that morning meds were not given and later noted the resident refused all meds due to difficulty swallowing, describing pooling of water and applesauce with crushed meds in the mouth and removal of the meds without ingestion. The nurse held the medications for the rest of the day and did not contact the provider about the missed doses or swallowing difficulty, while another nurse later reported administering the evening meds crushed in applesauce after extended effort. The physician and corporate nurse consultant later stated the MD should have been notified when the resident could not swallow medications.
A resident with a history of subdural hemorrhage, rib fractures, DM II, weakness, and unsteadiness fell after using the call light for bathroom assistance that was not answered, then attempted to ambulate alone and fell, reporting immediate severe right leg pain. Night-shift staff later lifted the resident from the floor, assisted with toileting, and returned the resident to bed without performing an assessment, documenting the fall, or notifying the MD, NP, or responsible party, despite the resident’s pain and verbal complaint. The oncoming nurse was not given a report of the fall. The next morning, a NA and a medication aide noted the resident’s significant pain and change in appearance, and the UM’s assessment found right leg pain, inability to bear weight, and limited ROM. Pain scores remained elevated throughout the day. Only after the UM’s involvement were the provider and family notified, imaging ordered, and a right hip fracture identified, demonstrating a failure to immediately notify the physician and responsible party of a change in condition following a fall.
A resident with type 2 DM had a new weekly semaglutide order entered into the EMR, but the drug was not available on multiple scheduled administration dates and was not actually given. An RN documented on the MAR that the dose was administered on one date and refused on another, later acknowledging these entries were incorrect and that the medication had been unavailable. There was no documentation that the MD/PA was notified that the ordered semaglutide was not being administered, and the PA reported she was unaware the medication had not been delivered or given until weeks later. The Administrator confirmed that providers are to be notified whenever a resident does not receive a prescribed medication, regardless of unavailability or refusal.
A resident with multiple comorbidities, including Type 2 DM, had a critically high blood glucose one week before a fatal decline, with only a one‑time insulin dose ordered and no ongoing BG monitoring documented afterward. Over the next several days, staff observed new respiratory symptoms, increasing sleepiness, markedly reduced oral intake, inability to drink through a straw, and decreased responsiveness, yet nursing staff notified the NP only of a cough and obtained an order for a CXR, without reporting the resident’s altered mental status, poor intake, or prior critical BG. Vital signs and BG checks were not consistently obtained despite these changes, and no additional provider consultation occurred until the resident was found extremely hot and in respiratory distress, prompting EMS transfer and subsequent death in the ED. Surveyors cited the facility for failing to notify the physician of all observed changes in condition and for not securing appropriate monitoring and treatment orders.
A resident with diabetes and diabetic polyneuropathy had a standing order for Gabapentin 800 mg three times daily, but multiple doses over several days were not administered because the medication was missing from the med cart. Medication aides and nurses documented the missed doses and reordered the drug through the electronic system, and one aide reported informing the nurse on duty, but no staff notified the NP or other provider as required by facility protocol. The unit manager was not informed of the missing medication, and the NP later stated she had been unaware of the missed doses and that the facility should have contacted her.
A resident with chronic constipation and gastroparesis had a provider order for Linzess 290 mcg, one capsule PO daily, but nurses and medication aides instead honored the resident’s request to take three capsules twice weekly. Staff routinely placed the daily capsule into a bedside bottle and, on designated days, removed three accumulated capsules and left them in a med cup for the resident to self-administer, while continuing to document the drug as given daily per order. Multiple nurses and med aides acknowledged they knew this practice did not match the written order yet did not notify the MD, NP, or DON of the resident’s ongoing refusal of the ordered regimen or the altered dosing schedule, and leadership and the NP reported they were unaware of the deviation until it was discovered during survey.
Surveyors found that nurses failed to notify a provider when a cognitively intact resident with DM II repeatedly did not receive ordered weekly Ozempic because it was documented as unavailable, despite pharmacy records showing delivery and multiple missed administrations recorded on the MAR. In a separate case, staff and a wound care NP identified and treated a new right heel DTI in a severely cognitively impaired resident, with orders entered for skin prep and offloading devices, but there was no documentation that the resident’s RP was informed, and the RP later reported learning of the wound only after a hospital transfer. Leadership interviews confirmed that provider and RP notifications, as well as documentation of those notifications, did not occur as required.
A resident with diabetes and failure to thrive had physician-ordered labs that could not be collected as scheduled. Nursing staff did not notify the NP or physician of the missed lab draw, following facility protocol to reschedule for the next day. The NP was not informed of the delay and stated that immediate notification was necessary to determine if further interventions were needed. This lack of timely provider notification when labs were not obtained led to the deficiency.
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