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 Providers and Families of Resident Changes in Condition: Staff did not document or complete required notifications for multiple residents after new skin tears, wound care needs, refusal of ADL care, and falls/accidents. Records showed an LPN and RN assessed and dressed wounds, but provider and family notification was not documented; one resident repeatedly refused bathing without physician or RP notification, and another resident’s falls were not consistently reported to family as required.
The facility failed to promptly notify resident representatives when two residents fell and had changes in condition. One resident with dementia and anxiety fell in the TV room and sustained a chin laceration, and another resident with schizophrenia, anxiety, and an unsteady gait had a witnessed fall in her room with a left upper arm skin tear. In both cases, the provider was notified and treatment orders were received, but the records did not document representative notification at the time of the events.
Failure to notify a resident’s DPOA of a new medication order. A resident with DM, vascular dementia, and moderately impaired cognition was newly ordered fluconazole, but the EMR lacked documentation that the DPOA was informed. The DPOA reported she had not been notified, and staff stated they were expected to call the family or representative about new meds or treatments and document the notification.
Failure to notify the MD and resident representative of a significant BiPAP setting change. A resident with CHF, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema had a physician order for BiPAP 28/5 with FiO2 40%. The RT changed the settings to 25/5 because the machine could not tolerate higher settings, but did not notify the MD, nursing supervisor, or representative, and did not document the change.
Failure to promptly notify the physician of a significant change in condition for a resident with acute respiratory failure and HF. The resident refused a newly ordered oral diuretic and continued to have low O2 sats despite an increased O2 order, but the record showed no documented physician notification. The resident was later found unresponsive.
A facility failed to notify the provider about missed meds for three residents and a change in condition for one resident. One resident with COPD missed 34 Duoneb treatments, another resident missed 12 hydromorphone doses and 10 pregabalin doses and later showed withdrawal symptoms, and a third resident missed 9 oxycodone doses because meds were out of supply. The record lacked evidence the provider was notified of the missed doses, and the resident with withdrawal symptoms also lacked timely provider notification of the change in condition.
Failure to Notify Providers and Families of Resident Changes in Condition
Penalty
Summary
The facility failed to notify residents’ physicians and/or resident representatives of changes in condition for multiple residents, including new or worsening skin issues, refusal of ADL care, and accidents. The report identified failures involving Resident #2, Resident #37, Resident #28, Resident #11, and Resident #30. The deficiency was based on observation, interview, and record review showing that required notifications were not documented after these events occurred. Resident #37 was observed with a bandage on the lower right forearm, and records showed wound care orders for skin tears to the arms and right wrist. The resident’s progress notes from 6/1/2026 through 8/10/2026 contained no documentation of notification to a provider or the resident representative regarding the wounds or dressings. Staff A, RN, the wound care nurse, stated she assessed the resident, found wounds on both forearms with dressings already in place, cleaned and redressed them, entered wound care orders, but did not write a progress note or contact a provider or the family. The physician stated he could not recall receiving a call about the wound, and the DON stated the wound care nurse was expected to notify family and a provider if a new or worsening wound was identified. Resident #2 had a skin tear to the left lateral ankle/left lower leg with a wound care order entered as a verbal order from Physician #2. The resident was observed with a gauze bordered dressing on the left lower extremity, and the resident stated the wound nurse had changed the dressing and said she would return later. Review of progress notes showed no documentation of the skin tear, no notification to family or provider, and no treatment orders documented in the notes. Resident #11 refused bathing on multiple occasions, but the record contained no documentation that the physician or resident representative was notified of the refusals. Resident #28 had a new skin tear to the right wrist that was bleeding and was assessed and dressed by nursing staff, but there was no documentation that the provider was notified. Resident #30 had a history of falls and skin tears, and the DON stated the family should have been notified for the resident’s falls; the report cited a failure to notify the resident’s family of the accident/change in condition as required.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to ensure residents’ representatives were immediately notified when residents fell or had a change in condition. The facility policy, revised in February 2021, stated that the resident, attending physician, and resident representative are to be promptly notified of changes in the resident’s medical or mental condition and/or status. Survey review found that this did not occur for 2 of 4 residents reviewed for changes in condition. Resident #7, who had diagnoses including major depressive disorder, dementia, and anxiety, fell while walking out of the doorway in the TV room and sustained a laceration to the chin. The provider was notified and orders were given for steri-strips and monitoring, but the record did not document that the resident’s representative was notified at the time of the fall. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteady gait, had a witnessed fall in her room and sustained a skin tear to the left upper arm. The provider and DON were notified and treatment orders were received, but the record did not document that the resident’s representative was notified at the time of the event.
Failure to Notify Legal Representative of New Medication Order
Penalty
Summary
The facility failed to ensure Resident 39’s legal representative was notified of a new medication order. Resident 39 had diagnoses of diabetes mellitus and vascular dementia, with a BIMS score of 8 indicating moderately impaired cognition. He was documented as alert to self, dependent on staff for toileting and personal hygiene, and newly admitted to hospice with vascular dementia. His care plan instructed staff to notify his durable power of attorney of any changes related to him. On 07/30/2026, the provider saw Resident 39 and ordered fluconazole 100 mg daily for 14 days, but the progress note did not document that the DPOA was notified. On 08/03/2026, the DPOA stated she had not been informed of the new fluconazole order and reported the facility had not always notified her of new orders. Staff interviews confirmed that the nurse should have called the family or representative about new medications or treatments and documented the notification in the EMR, and that it was expected for the nurse to notify the family or representative of all new orders and document it in the EMR.
Failure to Notify Physician and Representative of BiPAP Setting Change
Penalty
Summary
The facility failed to immediately consult the resident’s physician when a treatment was significantly altered. Resident #1 was admitted with congestive heart failure, rheumatic heart disease complicated by mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema. The Minimum Data Set documented moderately impaired cognition, and the resident required continuous oxygen therapy and non-invasive mechanical ventilation (BiPAP). A physician’s order dated 07/15/2026 specified BiPAP settings of IPAP 28 and EPAP 5, with FiO2 40 percent at bedtime as tolerated and removed in the morning. On 07/16/2026, the Director of Respiratory Therapy changed the BiPAP settings from 28/5 to 25/5 because the machine could not tolerate settings over 25/5. The Director of Respiratory Therapy stated they did not review the physician’s order before ordering the BiPAP machine, did not notify the physician, nursing supervisor, or the resident’s representative of the change, and did not document the events in the medical record. The resident’s representative stated they were not notified of the change, the RN stated they were not informed that the settings had been changed, and the Medical Doctor stated they were not aware the BiPAP machine had not been delivered on 07/15/2026 or that the ordered settings had been changed.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify the attending physician of a significant change in condition for Resident 107. The resident was admitted with diagnoses including acute respiratory failure and heart failure, and a quarterly MDS dated May 26, 2026, showed the resident was cognitively intact with a BIMS score of 15. On June 30, 2026, the resident was seen for weight gain and increasing oxygen requirement. The physician documented that the resident refused an intramuscular diuretic that morning, continued to refuse hospitalization or a change in code status, and had new orders to increase oxygen to 5.0 L/min and later increase oral furosemide to 80 mg twice daily. Later that day, the resident refused the newly ordered oral furosemide 80 mg. The clinical record showed repeated low oxygen saturation readings despite the increased oxygen order, including values of 87% to 89% on June 30 and 88% on July 1 while on nasal cannula oxygen. The record contained no documented evidence that the facility notified the physician of the resident’s refusal of the oral furosemide or of the continued low oxygen saturation after the revised oxygen order was implemented. A progress note on July 1, 2026, at 5:30 AM documented that Resident 107 was found unresponsive. During an interview on July 31, 2026, the Nursing Home Administrator and DON reviewed the findings and confirmed there was no documented evidence that the physician had been notified after the resident refused the newly prescribed oral furosemide or continued to have oxygen saturation levels of 87% to 89%.
Failure to Notify Provider of Missed Medications and Change in Condition
Penalty
Summary
The facility failed to notify the provider of missed medications for three residents reviewed for medication errors. R4, who was cognitively intact and had diagnoses including vascular parkinsonism, heart failure, and COPD, had an order for Duoneb nebulizer treatments three times daily for COPD. The July MAR showed 34 missed Duoneb treatments from 7/9/26 through 7/20/26, and progress notes documented that staff noted no supply for each missed treatment. R4 also requested a PRN nebulizer treatment for shortness of breath on 7/16/26, but the record lacked evidence that the provider was notified of the missed treatments. R20, who was cognitively intact and had diagnoses including COPD, type 2 diabetes with diabetic neuropathy, anxiety, and moderate protein-calorie malnutrition, had long-term orders for hydromorphone 4 mg BID and pregabalin 100 mg TID for chronic pain. The July 2026 MAR showed 12 missed hydromorphone doses and 10 missed pregabalin doses because the medications were out of supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed doses. R20 later had documented complaints of not feeling well, loss of appetite, SOB, skin crawling, difficulty sleeping, and signs and symptoms of withdrawal, and the on-call NP stated the nurse had requested only refill orders and had not reported the missed doses or symptoms. R22, who had moderate cognitive impairment and diagnoses including COPD, spondylosis, and chronic pain syndrome, had an order for oxycodone 5 mg BID for chronic pain syndrome. The July MAR showed 9 missed oxycodone doses from 7/18/26 through 7/22/26 because there was no supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed oxycodone doses. The facility’s Change in Condition policy stated that the facility would inform the resident, consult with the physician, and notify the resident representative when a change occurred, and the DON stated nurses were expected to notify the provider in SBAR form for missed medications and changes in condition.
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