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 diabetes, hemiplegia, and moderate cognitive impairment, who was dependent for toileting and bed mobility, was found by CNAs to have new purple discoloration and dry, scratch-like areas on the trunk/back after a reported fall the previous day. An LVN assessed the area, documented the findings, and noted the resident’s statement that it resulted from the fall, but did not notify the physician, initiate a change in condition assessment, or ensure notification of the resident’s representative, believing the discoloration was part of the prior fall incident. The DON confirmed that no follow-up with the physician or change in condition/skin assessment was completed because the discoloration was considered related to the earlier fall, contrary to the facility’s policy requiring prompt notification of changes.
Two cognitively impaired residents on a memory care unit were involved in an incident in which one was found in another’s room, in that resident’s bed, nude from the waist down and covered with a blanket, while the other sat across the room. Nursing staff assessed both residents, redressed and redirected the disrobed resident, and documented the event, but did not promptly notify either resident’s representative or physician, despite care plan and policy requirements to inform family and consult the MD for changes or concerns. Interviews with the residents’ representatives, nursing staff, hospice RN, and leadership confirmed that the representatives and physicians were not informed at the time of the incident, and that leadership assumed, without verification, that notifications had been made.
A resident with a PEG tube, dysphagia, and anorexia was admitted on a pureed "pleasure" diet with orders for enteral feeds and oral Ensure, but staff did not administer tube feeding formula and documented repeated refusals of oral supplements and medications over multiple days without promptly notifying the NP/MD or the resident’s representative. The resident was observed alone with an uneaten pureed meal tray, reported only receiving water flushes through the PEG and difficulty swallowing, and described disliking the pureed food. Medication aides stated the resident had not taken oral meds or Ensure since admission due to swallowing problems and that they verbally informed charge nurses, while the RN and DON acknowledged they were unaware of the full extent of refusals and had not ensured timely provider notification. The NP and MD confirmed they had not been informed of the resident’s ongoing refusals or lack of a clear enteral feeding regimen, leading surveyors to cite the facility for failing to immediately inform and consult with the practitioner and representative when significant treatment changes were needed.
A resident with severe cognitive impairment and multiple comorbidities exhibited significant nighttime behavioral changes, including yelling, refusing care, and repeatedly attempting to get out of bed and crawl onto the floor. Staff placed a mattress on the floor for the resident to sleep on and documented that she would not stay in bed and was observed resting on the floor mattress. The following day, an LVN and CNA repeatedly observed the resident on the floor mattress, allowed her to continue sleeping there, and did not verify or ensure that the physician or MPOA had been notified of the behavior change or the mattress-on-floor intervention. Family members later reported they were not informed by staff that the resident was sleeping on the floor, and facility leadership and nursing staff acknowledged that the physician and family should have been notified of these changes, consistent with the facility’s Resident Rights policy requiring notification of changes in condition.
A resident with dementia, prior septic shock, and a history of falls was on 72‑hour neuro checks after a fall with head injury when BP and HR dropped well below his established baseline, triggering first‑time use of PRN Midodrine ordered for SBP <90. An LVN administered the PRN Midodrine and documented it as effective, but there was no documented follow‑up assessment, no contemporaneous neuro‑check findings addressing the episode, and no notification to the provider despite the facility’s policy requiring consultation for significant changes in condition and new treatment. The next morning, staff observed new left‑sided facial droop, weakness, and inability to mouth words, EMS was called for possible stroke, and the resident was sent to the hospital, where he was found to be hypotensive and diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy.
Two residents experienced failures in required notifications regarding significant changes in status and care decisions. One resident with dementia and other comorbidities was transferred to another facility’s memory care unit without prior notification to her RP; staff interviews showed that multiple staff assumed others had notified the family, and there was no documentation of timely communication. Another resident with severe cognitive impairment and multiple medical conditions was found on a floor mat by CNAs, who reported the event to the nurse; the nurse did not treat the event as a fall, did not notify the RP or MD, and did not document the incident. Days later, a nurse identified bruising and pain in the resident’s arm, notified the NP, and obtained x-rays that revealed an acute humeral head fracture, with the RP only informed of the injury and imaging, not the earlier fall.
Failure to Notify Resident Representative After Resident-to-Resident Incident: A resident with dementia and severe cognitive impairment was involved in a resident-to-resident altercation that caused a scratch to the right forearm. The progress note and incident report did not show that the RP was notified, and interviews confirmed the RP was not informed even though staff said family notification was expected for verbal or physical altercations.
Failure to Notify Responsible Party of Fall and New Wound: A resident with dementia, schizophrenia, and high fall risk had a fall with a skin tear above the eye and later had a new sacral pressure wound identified. Records and staff interviews showed the family member/medical POA was not notified of the fall or the new wound, while the federal fiduciary listed in the chart handled only VA finances and was not the resident’s medical decision-maker.
A resident with brain cancer, cerebral edema, seizure disorder, and a history of falls was admitted with elevated BP and multiple ordered meds, some of which were documented as unavailable, and there was no documented MD/NP confirmation of her medication regimen. In the early morning, she sustained an unwitnessed fall and developed a forehead hematoma; nursing notes show she was found on the floor and later transferred to the hospital, but her family reports they were not called, discovered the injury only after arriving on-site, and found her call light out of reach. The family also reported the RN was off the unit in his car, appeared unaware of the extent of the head injury, stated he was overwhelmed by his caseload, and initially resisted calling 911 despite the family’s request. The NP later confirmed she had not been notified of the fall or medication issues, and the administrator stated nurses are expected to assess, perform neuro checks, and immediately notify the physician and family after a fall, supporting the deficiency for failure to immediately inform the physician and family and to appropriately respond to the resident’s change in condition.
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