Two residents experienced significant changes in condition without appropriate notification of their POA/emergency contacts or providers. One resident with complex neurologic and vascular diagnoses had multiple documented CIC events, including abnormal vitals with unresponsiveness, seizures, falls with head injury, COVID‑19 infection, swallowing difficulties, and an altercation, yet staff consistently notified only a resident representative who was not the POA, despite clear documentation that the spouse and then the son were to be notified first. Another resident with dementia, chronic respiratory failure, CHF, and hypoglycemia, and designated as full code, developed mouth breathing with gurgling, low O2 saturation requiring increased oxygen, abnormal lung sounds, and decreased responsiveness; the nurse placed this information in a non‑emergent provider log instead of directly contacting a provider or EMS. Later that morning, staff found the resident unresponsive, initiated CPR, and a code blue was called, with the DON and NP confirming that no provider notification had occurred despite the clear CIC.
A resident experienced a fall and was transferred to a hospital, but the resident’s daughter reported she was not informed by facility staff and only learned of the incident when the hospital called for treatment permission. The hospice DON stated hospice was not notified until after the resident returned from the ER, while an LPN reported notifying hospice later that morning and asserted that hospice, not the facility, is responsible for informing the family. The DON stated that facility practice is to notify the family, physician, and hospice for residents on hospice but could not confirm that such notifications occurred in this case.
A resident with Parkinson’s disease had an active order for carbidopa-levodopa four times daily and a care plan instruction that the resident’s son be notified of any medication changes or behaviors. Nursing staff placed the Parkinson’s medication on hold to assess behaviors and, after the resident developed weakness and arm shaking, the physician ordered a reduced dosing schedule. The resident reported not knowing the medication had been stopped until his hands began shaking, and the son, identified as POA, stated he was not informed of the discontinuation or change despite the care plan directive. The Administrator confirmed that the son should have been notified before altering the resident’s Parkinson’s medication and that this did not occur.
A resident with Parkinson’s disease, dementia, and epilepsy was observed on multiple occasions receiving O2 at 2 L/min via nasal cannula from an oxygen concentrator, with documentation showing an SpO2 of 98% on O2 but no corresponding physician order. An LPN reported initiating O2 after noting desaturation into the low 80% range and increasing weakness, without obtaining a physician order and without consistent documentation of O2 use, SpO2 levels, or desaturation episodes. The ADON was unaware O2 had been started and could not find evidence of physician notification, orders, or supervisory review, while the DON and medical director both confirmed they had not been notified despite expectations for notification and appropriate orders when O2 is initiated after a change in condition.
A resident with multiple comorbidities, including muscle wasting, morbid obesity, endocrine disorders, and mild cognitive impairment, developed a skin tear on the LLE after bumping it on a door. Nursing staff documented the initial wound, subsequent dressing changes, surrounding redness, and later an open lesion with 5+ pitting edema, but several weekly skin assessments lacked measurements and there were gaps in wound documentation. Despite ongoing non-healing of the wound and no improvement, there were no changes in wound care orders for an extended period, and nursing staff did not notify the provider of the lack of progress. The DON confirmed the absence of provider notification and treatment changes during this time, and the NP reported she relied on nurses for wound status and had not been informed that the wound was not improving.
A resident with depression and anxiety did not receive prescribed doses of Venlafaxine for several days, and the facility failed to promptly notify the MD about the missed medication. The lapse in communication was confirmed by both the DON and MD, and the resident experienced suicidal thoughts during the period without medication.
A resident with multiple chronic conditions experienced a decline and a change in diet after returning from the hospital. Although the legal guardian was listed as the primary contact, staff failed to notify the guardian of these changes, with documentation and interviews confirming the lack of communication. Instead, a different family member was contacted, and the guardian remained unaware of the resident's updated condition and care needs.
Staff did not notify providers when two residents had repeated low blood pressure readings and antihypertensive medications were withheld, nor when another resident experienced multiple low blood sugar episodes. Required notifications and documentation were not completed according to physician orders and facility policy, as confirmed by the DON.
A resident with glaucoma, dementia, and cataract developed a red, swollen eye with mucus drainage, which staff observed but did not document or report to the physician or DON. The RN wiped the eye but failed to notify appropriate personnel or record the incident, contrary to facility expectations for reporting changes in resident condition.
The facility did not promptly notify providers and a guardian about a resident's fall with injury, delayed informing the wound care nurse about another resident's scalp staples after a fall, and failed to timely alert providers about a third resident's worsening pressure ulcers. These lapses in communication were confirmed by interviews with staff and documentation review.
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