Failure to Notify Physician of Fall and Delay in STAT X-ray Order
Summary
The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall while being transferred to the toilet using a sit-to-stand mechanical lift. The CNAs involved did not report the incident to a nurse or physician, and the resident was moved without a proper assessment. The resident later displayed signs of pain and decreased range of motion in her left hip, leading to a STAT x-ray order that was delayed without notifying the physician of the delay. The x-ray eventually revealed an acute fracture of the left hip, and the resident was transferred to the ER for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired. The incident began when an agency CNA was lowering the resident to the toilet, and the resident's foot slipped, causing her to be lowered to the floor. The CNA did not report the incident to a nurse, believing it was not a fall. Another CNA assisted in moving the resident back to her chair without notifying a nurse for an assessment. The following day, the resident's decreased mobility and pain were noticed, and a STAT x-ray was ordered. However, the x-ray was delayed, and the physician was not informed of the delay. Interviews with the involved staff revealed a lack of communication and understanding of the facility's protocols for reporting falls and changes in condition. The CNAs did not recognize the incident as a fall and failed to notify the appropriate medical personnel. The delay in the STAT x-ray order was not communicated to the physician, resulting in a delay in the resident's diagnosis and treatment. The facility's failure to follow proper notification procedures contributed to the resident's prolonged pain and delayed medical intervention.
Removal Plan
- The facility failed to notify the MD/NP and RP when Resident #1 fell and failed to notify the NP when there was a delay in a stat x-ray order. C.N.A. #1 and C.N.A #2 failed to notify a Nurse/MD or NP when Resident #1 fell and failed to notify before moving Resident #1 off the floor. C.N.A. #2 informed the NP that Resident #1 was having issues with her foot dragging. C.N.A #2 did not notify the NP of the fall. NP performed an assessment on Resident #1, no bruising or swelling was noted. NP ordered stat x-ray and changed scheduled Tylenol to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification of MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment.
- Director of Nursing and/or designee completed education with all licensed nurses and CNA's including agency staff on notification to MD/NP and RP of all incidents or falls and accidents.
- Director of Nursing and/or designee completed education with all licensed nurses including agency staff on notification to MD/NP on delay of stat x-rays orders. Interviews were conducted with communicative residents. These interviews were conducted to determine if any issues regarding care and services would be identified. No other issues were identified. Unit managers completed skin checks on all residents. Skin checks were completed to ensure there were no signs of injury from an unreported fall, no negative findings were noted. Director of Nursing checked for any other stat x-ray orders and there were none.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses including agency staff on reporting of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff including agency staff on reporting of accidents and incidents. The Director of Nursing and/or their designee educated all licensed nurses including agency nurses on stat orders and procedures. This education included notification to physician or NP on a delay of stat orders or other changes of condition for the residents.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure order for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will audit change of condition and incident reports daily for 12 weeks to ensure physician notification of incidents/accidents and falls has been completed. Director of Nursing and/or designee will have daily huddles with licensed nurses and C.N.A.'s at beginning and end of shift to discuss any change in condition or incidents that may have occurred throughout the shift in order to ensure proper notifications have been made. This is to ensure that MD/NP have been notified of any incidents. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
A resident with severe cognitive impairment and a history of falls, weakness, malnutrition, and difficulty walking was found on the floor and later developed persistent right hip, thigh, and RLE pain with inability to bear weight. PT and OT notes documented worsening pain and limited mobility, but progress notes did not show notification to the MD or NP. The resident was later sent to the hospital, where imaging showed a displaced right femoral neck fracture.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
A resident had an unwitnessed fall, but the physician and resident representative were not notified until the next morning. The facility’s policy required prompt assessment and notification after a fall, and the resident had capacity to understand and make decisions. An LVN said the delay occurred because the resident did not show a change in condition, while an RN stated the nurse should have notified the physician and representative immediately after assessing the resident.
A facility failed to notify family representatives about missed morning medications for eight residents. MARs showed blank administration entries for the medication pass, and Progress Notes did not document family notification. Interviews with family members and the POA confirmed they were not told about the medication omissions, while the DON stated notifying families of medication errors is standard practice and should be documented.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Notify Provider of New Right Hip Pain and Inability to Bear Weight
Penalty
Summary
The facility failed to follow its policy for notification of a change in resident condition by not notifying the physician and/or nurse practitioner when a resident developed new right lower extremity pain and inability to bear weight. The resident had a history that included weakness, unspecified fall, hypotension, severe protein calorie malnutrition, major depressive disorder, cognitive communication deficit, metabolic encephalopathy, and difficulty walking, and had a BIMS score of 4/15 indicating severe impairment. After the resident was found on the floor on the right side next to the bed with lacerations, redness to both knees, a laceration to the right ankle, and redness to the right hip, the resident initially denied pain. Subsequent PT and OT documentation repeatedly recorded pain in the right hip, thigh, and right lower extremity, with pain increasing with movement, sitting, standing, bending, and weight bearing. PT notes documented that the resident required walker support, took only a few small steps with max assist due to pain, later became unable to ambulate because of severe right lower extremity pain, and was unable to put weight on the leg and had difficulty standing. OT notes also documented aching right lower extremity pain that limited lower body ADLs and functional mobility tasks. The progress notes did not document notification to the doctor or nurse practitioner about the pain or the changes in the resident's right lower extremity. When the resident was later sent to the hospital at the family’s request, the nurse practitioner and ADON were made aware, and the resident was transported by ambulance. The hospital record documented right hip pain, tenderness to palpation and with range of motion of the right hip, and x-ray findings of a superolateral displaced right femoral neck fracture. The hospital history noted the resident may have fallen two weeks earlier, and the daughter reported the last time she saw the resident walking was four weeks earlier. Staff interviews indicated the APRN and NP were not notified of the pain or inability to bear weight, and both stated they would have assessed the resident and likely ordered an x-ray if they had been informed.
Failure to Notify Legal Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident's legal representative of a significant change in condition for one resident reviewed for notification of changes. The resident was admitted with pneumonitis due to inhalation of food and vomit, dysphagia, and stage 3 chronic kidney disease. The Minimum Data Set dated 05/06/2026 documented that the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. On 05/14/2026, the resident experienced a vasovagal episode while in the shower and later had episodes of vomiting, including brown-colored emesis. Progress notes documented that staff notified the PA of the resident's condition, assessed the resident, and monitored vital signs. The facility policy titled Notification Policy required the attending physician or designee and the resident or resident's legal representative or interested family member to be notified by the nurse of a significant change in condition, including vomiting, change in mentation, change in vital signs, or respiratory distress. There was no documented evidence that Family Member #2 was immediately notified of the vasovagal episode or the vomiting. Family Member #2 stated they were not informed of these events and first learned from the facility when told the resident had passed away at 12:07 PM. Staff interviews confirmed that family notification was expected for significant changes, and the PA stated they were contacted about the vasovagal episode, the vomiting, and later the resident's death.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Delayed Notification After Resident Fall
Penalty
Summary
The facility failed to notify Resident 4’s physician and resident representative of an unwitnessed fall in a timely manner. The facility’s Fall Prevention and Response policy stated that after a fall, a licensed nurse shall promptly respond, assess the resident, and notify the physician and resident representative. Resident 4 was admitted to the facility and had an H&P showing the resident had the capacity to understand and make decisions. Resident 4’s SBAR Fall Report documented a fall on 5/3/26 at 2330 hours, but the physician and resident representative were not notified until 5/4/26 at 0744 hours. LVN 1 stated the resident was monitored closely after the fall and that notification was delayed until the following morning because the resident did not exhibit a change in condition. RN 1 verified the fall occurred and stated the licensed nurse should notify the physician and resident representative immediately after assessing the resident rather than waiting until the next morning. The DON was informed and acknowledged the findings.
Failure to Notify Families of Missed Morning Medications
Penalty
Summary
The facility failed to notify resident family representatives of missed administration of significant morning medications for eight residents. Review of the Medication Administration Records for R1, R2, R3, R4, R5, R6, R7, and R8 showed blank boxes without nurses’ initials to indicate the medications were administered on 5/10/26 during morning medication pass. The residents’ Progress Notes did not document that family representatives were notified of the medication omission errors. Interviews confirmed the lack of notification. On 5/21/26, R8’s POA stated the facility did not notify her that R8 missed medications on Mother’s Day. On the same day, R1’s family member stated she was not contacted about the missed medications, and R2’s family member stated no one called or told him there were problems with his father receiving medications. The Interim DON stated it is standard practice for family representatives to be notified of medication errors, that floor nurses are expected to contact families, and that the notification should be documented in the resident’s medical record. The facility policy on Physician-Family Notification-Change in Condition states the facility will inform the resident, consult the physician or authorized designee, and if known, notify the legal representative or interested family member.
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