Failure to Notify Resident Representative of Discontinued Dementia Medication
Summary
The facility failed to notify a resident’s representative of a significant medication change, specifically the discontinuation of donepezil, as required by its own Resident Change of Condition/Status policy. That policy, dated 4/11/25, states the facility must inform the resident, consult with the physician, and notify the resident’s family member or legal representative when there is a change requiring notification, including alterations in treatment such as new treatments or discontinuation of current treatments. The policy further notes that even when residents are cognitively competent, the physician must be contacted and the representative notified, particularly when a family has requested to be informed of significant health status changes. Resident #6, an older adult with dementia and frontal lobe/executive function deficits, was cognitively intact per a recent MDS (BIMS score 14/15) and dependent on staff for ADLs. A pharmacist note dated 10/30/25 recommended deprescribing donepezil due to lack of demonstrated efficacy and potential side effects; this recommendation was signed by the physician on 12/22/25, and the physician’s order shows the donepezil was discontinued on 1/7/26. Record review revealed no documentation that the facility communicated with the resident or the resident’s representative about either the pharmacist’s recommendation or the actual discontinuation of the medication. The resident’s representative reported she was not contacted prior to the discontinuation and only learned of it approximately two months later, which upset her. The DON confirmed in interview that the representative was not notified when the medication was discontinued, despite the facility’s policy and the resident’s capacity to understand medication changes.
Penalty
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Surveyors found that the facility failed to notify two residents’ representatives when the residents experienced significant changes in condition, despite a policy requiring such notification. One resident with multiple chronic conditions, mild cognitive impairment, and dependence for transfers developed chest pain and was sent to the ER without the POA being informed. Another resident with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD developed abdominal pain, spasms, and audible wheezing, leading to imaging, labs, and medications being ordered, but again without POA notification. In both cases, the Administrator confirmed that the representatives were not notified.
A cognitively impaired resident with a court-appointed guardian, whose care plan specified 24-hour supervision, elopement risk monitoring, and that he not leave without guardian permission, exited the facility grounds unsupervised on more than one occasion, including traveling down a hill and along a street toward a nearby park before being found near the road and refusing to re-enter. Staff interviews confirmed awareness of his impaired cognition and guardian status, and that he was expected to report when going outside, yet medical record review showed no documentation that his physician or legal guardian were notified of his unsupervised departures, contrary to the facility’s elopement policy requiring physician and legal representative notification when a resident leaves the facility.
The facility failed to notify a practitioner when ordered medications were unavailable for two cognitively intact residents with anxiety, depression, and seizure disorders. One resident with anxiety and depression had multiple scheduled doses of Ativan omitted because the drug was out of stock or awaiting pharmacy delivery, as documented on the MAR and in progress notes, and the NP later confirmed he had not been informed of these missed doses. Another resident with a seizure disorder missed several scheduled doses of Phenobarbital when only part of a dose was available and then the medication was not in stock, with the resident and an LPN confirming the omissions and the NP again stating he was not notified. These events occurred despite a facility policy requiring prompt physician notification when medications cannot be administered as ordered.
A resident with metabolic encephalopathy, chronic respiratory failure, osteoporosis, ESRD, and moderate cognitive impairment experienced right shoulder pain, requested hospital evaluation, and had an NP-ordered shoulder x-ray and ibuprofen initiated. The resident later was sent from dialysis to the hospital for hypoglycemia. Although both the resident and her mother were listed as primary contacts, there was no documentation that the representative was notified of the pain, diagnostic testing, treatment orders, or hospital transfer; a regional nurse stated the mother was not notified because the resident was alert, oriented, and listed as primary contact.
A resident with multiple serious conditions, including COPD, respiratory failure, lung cancer, heart failure, and syncope, returned from the hospital with an order for Midodrine 10 mg PO TID for symptomatic orthostatic hypotension. The facility documented that several scheduled doses were not administered because the medication was not yet available from the pharmacy, and MAR entries showed missed AM and mid-day doses with only a later HS dose given. Nursing progress notes recorded that the drug was unavailable, but there was no documentation that the physician was notified of the missed ordered doses. The DON confirmed that the medication was not given as ordered and that there was no evidence of physician notification regarding the unavailability of the Midodrine.
A resident with significant cognitive and communication impairments, including aphasia and psychosis, was sent to an outside cancer center for evaluation of anemia, accompanied by an aide who lacked knowledge of the resident’s history, status, complaints, or the reason for the visit. The next day, staff identified a large bruise and fluid-filled area with an open tear on the resident’s leg, along with fever and concern for cellulitis, and notified the physician, DON, and NP, who ordered treatment. However, the resident’s involved representative was not notified of the outside appointment, the reported transport incident, the leg injury, or the subsequent change in condition until the resident was later sent to the hospital, despite facility policy requiring prompt notification of the representative for changes in condition and incidents resulting in injury.
Failure to Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives of significant changes in condition, as required by facility policy. For one resident with multiple complex diagnoses including acute kidney failure, heart failure, stage three chronic kidney disease, symptomatic epilepsy, and obstructive sleep apnea, the quarterly MDS showed mild cognitive impairment, use of a walker and manual wheelchair, and a need for maximal assistance with transfers and moderate assistance with ADLs, as well as use of dialysis services. A progress note documented that this resident experienced chest pain and was sent to a local emergency room for treatment, but there was no documentation that the resident’s power of attorney (POA) was notified of this change in condition. In an interview, the Administrator confirmed that the POA had not been notified of this event. A second resident, admitted with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, had a quarterly MDS indicating mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with ADLs. A progress note documented that this resident experienced abdominal pain, spasms, and audible wheezing, and that imaging, labs, and medications were ordered in response. However, there was no indication in the record that this resident’s POA was notified of the change in condition. In an interview, the Administrator confirmed that the POA had not been notified. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” stated that the facility would notify a resident’s representative in the event of a significant change in condition, which did not occur for these two residents.
Failure to Notify Physician and Legal Guardian After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and legal guardian when the resident exited the facility without supervision and left facility property, despite existing care plan instructions and facility policy. The resident had multiple diagnoses including cognitive deficit, cerebral infarction, aphasia, mood and adjustment disorders, and was determined by a court to be incompetent, with a legal guardian appointed. The resident’s care plan documented that he required 24-hour care related to cognition, that he had a guardian, and that staff were not to allow him to leave without the guardian’s permission, with interventions to observe for risk or desire to elope. The facility’s Elopement Policy defined elopement as a resident who needs supervision leaving a safe area without authorization or necessary supervision, and required that if a resident leaves the facility, upon return the DON should notify the Administrator, examine the resident, contact the physician, and contact the resident’s legal representative. Interviews and record review showed that on one evening the DON reported the resident was outside and down the street from the facility, near a park located 0.6 miles away, and staff subsequently found him at the end of the facility’s long sidewalk near the road, at the base of a hill on the left side of the property, where he refused to re-enter the building. The resident reported that he had gone down the hill in front of the facility and down the street without staff present, and that he had left the facility grounds on another day as well. The receptionist stated the resident, who had impaired cognition and a legal guardian, was supposed to report to her when exiting, and that on two separate days she observed him re-enter the facility without knowing he had been outside. Medical record review revealed no documentation that the physician or legal guardian were notified that the resident had left facility property or was going outside unsupervised. The legal guardian and the medical director both confirmed they were not notified of the incident, and the guardian stated she was upset to learn the resident could go outside unsupervised.
Failure to Notify Physician of Unavailable Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification when ordered medications were unavailable for two residents. For Resident #10, who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions, the care plan required administration of anti-anxiety medications as ordered and monitoring for side effects and effectiveness every shift. The resident had a physician’s order for Ativan 0.5 mg by mouth twice daily for anxiety and agitation. The MAR showed that the evening dose on 04/18/26 and the morning dose on 04/19/26 were not administered, with documentation indicating the medication was unavailable and on order or awaiting pharmacy delivery. Resident #10 reported having anxiety and depression and stated that the facility had run out of her Ativan. An LPN confirmed that the resident did not receive the ordered doses on the evening of 04/18/26 and the morning of 04/19/26. The NP stated that missing two doses of Ativan can cause disruption in treatment and increase the resident’s anxiety and confirmed that he was not notified by the facility of the missed doses. The facility’s policy titled “Change in a Resident’s Condition or Status,” revised May 2024, required prompt physician notification of changes in condition, including inability to administer medications as ordered. For Resident #19, who was also cognitively intact with a BIMS score of 15 and had diagnoses including convulsions, anemia, stage four chronic kidney disease, major depressive disorder, syncope and collapse, tremor, cerebral infarction, and seizures, the care plan addressed sedative/hypnotic therapy related to convulsions/seizure disorder, with interventions to administer medications as ordered and monitor side effects and effectiveness every shift. The resident had orders for Phenobarbital 32.4 mg by mouth every morning and 129.6 mg in the evening for seizures and convulsions. The MAR showed that the evening doses on 04/17/26 and 04/18/26 and the morning dose on 04/18/26 were not administered, with progress notes documenting that only part of the dose was available on 04/17/26 and that the medication was not available and on order on 04/18/26. Resident #19 reported not receiving Phenobarbital since the morning of 04/17/26, and an LPN verified the missed doses. The NP confirmed that he was not notified of these missed doses, despite the facility’s policy requiring physician notification when medications cannot be administered as ordered.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of changes in condition and treatment decisions. The resident was admitted with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure with hypoxia, osteoporosis, and end stage renal disease, and had moderate cognitive impairment requiring extensive assistance with all ADLs. The care plan identified a risk for pathological injuries/falls and pain related to osteoporosis, with interventions to keep personal items and the call light within reach. The face sheet listed the resident herself as a primary contact and also listed her mother as a primary contact. On one evening, nursing documentation showed the resident requested to go to the hospital due to right shoulder pain that had been present since the prior day and refused PRN Tylenol. The NP was notified, an x-ray of the right shoulder and ibuprofen were ordered, and the resident initially refused but then agreed to the x-ray and ibuprofen, stating she would go to the hospital the next day if the pain persisted. There was no evidence in the record that the resident’s representative was notified of the shoulder pain, the x-ray order, or the resident’s request for hospitalization. The following morning, while at dialysis, the resident was sent to the hospital for evaluation due to hypoglycemia, and again there was no evidence that the representative was notified of the transfer. In an interview, the regional nurse stated the resident’s mother was not notified because the resident was alert and oriented and listed as the primary contact.
Failure to Notify Physician When Ordered Hypotension Medication Was Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician when an ordered medication for hypotension was not available and therefore not administered as prescribed. The resident was admitted with multiple serious diagnoses, including COPD, acute on chronic respiratory failure with hypoxia, lung cancer, dependence on supplemental oxygen, heart failure, syncope and collapse, sepsis, and shock. After an unwitnessed fall with hip pain, the resident was hospitalized and later discharged back to the facility with an order for Midodrine 10 mg by mouth three times a day before meals for symptomatic orthostatic hypotension. Hospital records showed the last dose was given on the morning of discharge, and the next dose was due that evening. The facility entered the Midodrine order on the MAR as 10 mg three times a day (AM, Mid, HS), but the mid-day dose on the day of return was not administered, with a code indicating “other/see progress notes.” Progress notes documented that the scheduled Midodrine dose due that evening could not be given because the facility was waiting on the pharmacy to deliver the medication. Review of the MAR for the following day showed that both the morning and mid-day doses were not administered, and the first documented dose given at the facility was the HS dose that day. A nurse’s note indicated the medication was not administered as ordered because it had been ordered and was not available, but there was no documentation that the physician was notified that the resident had missed multiple ordered doses since the previous evening. During interview, the DON confirmed there was no evidence of physician notification regarding the missed Midodrine doses due to pharmacy non-delivery and verified that the medication was not given as ordered on the dates in question. This deficiency was identified during investigation of a complaint.
Failure to Notify Resident Representative of Injury, Change in Condition, and Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of significant changes in condition and of an outside medical appointment. Resident #5, admitted with multiple serious diagnoses including cerebral infarction with right-sided hemiplegia/hemiparesis, psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, diabetes, muscle atrophy, and aphasia, was care planned as dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits and disease processes. The Medication Administration Record showed an outside appointment at a cancer treatment center (The Hope Center) for evaluation of anemia. At that appointment, the Hope Center physician documented that the resident had aphasia, chronic psychosis, could not provide history or answer questions, and only stated that his right leg hurt. The physician further documented that the aide accompanying the resident did not know the resident’s health history, status, complaints, or the reason for the visit, and that all history had to be obtained from records sent with the referral. On the following day, nursing documentation showed discovery of a significant right lower extremity injury. An STNA alerted LPN #722 to a large bruise and fluid-filled sac on the resident’s right leg. The LPN documented an 11 cm by 16 cm bruise with a fluid-filled sac measuring approximately 6 cm by 11 cm and a central tear with serosanguineous drainage; the area was drained, cleansed, and dressed, and the DON and physician were notified. A subsequent note by the DON indicated she came in to assess the bruise and recorded that the ADON reported an incident on the transport bus the previous day in which the resident slid down in a chair and the left leg pressed against the footrest, which the DON stated lined up with the placement and injury. The DON documented that the practitioner was notified and new wound care orders were obtained, and that she left a message with family to notify them of the bruise. However, there was no documentation in the record that the resident’s representative was actually notified of the injury. Additional progress notes on the same date documented a change in condition including a temperature of 100.7°F, pain, concern for cellulitis, and initiation of antibiotics and Tylenol after notification of the primary care provider and a nurse practitioner, again without any indication that the resident’s representative was notified. The resident was later sent to the emergency room after being found with slurred speech, shaking, and eyes rolling back, at which time the family and DON were notified. In interviews, LPN #722 acknowledged she did not notify the son of the leg injury and that the son reported he had not been informed of the bruise, fever, pus, or the cancer center appointment, and would have attended the appointment had he known. The Ombudsman and the resident’s son both confirmed that the son was not notified of the transport incident, the appointment, or the subsequent leg injury and symptoms. The DON later confirmed she did not notify the representative when the bruise was found, stated she might have left a message, did not recall speaking with him, and suggested she may have called the wrong number. Facility policy required prompt notification of the resident’s representative of changes in condition and any incident resulting in injury, including injuries of unknown source, which was not followed in this case.
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