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:
A resident with diabetes, hypertension, and dementia had physician orders for Accu-Chek blood glucose monitoring four times daily, with instructions to notify the provider for readings below 90 or above 350. The care plan required staff to obtain blood sugars as ordered and notify the physician of abnormal results. Review of the MAR showed multiple low and high blood sugar values documented as abnormal, yet marked with "N" indicating no physician notification. An LPN confirmed that an "N" entry meant the physician was not notified, and the Executive Director could not locate documentation of any notifications for these abnormal readings and acknowledged there was no facility policy for call orders and physician notification.
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Licensed nurses failed to notify a resident’s representative of two significant changes in condition: an elopement and a subsequent fever. The resident had severe cognitive impairment, was deemed unable to make his own health decisions, and had a Wanderguard order for exit-seeking behavior. After the resident left the building and was returned by police, there was no documentation that the representative was informed. Later, when the resident developed a fever with respiratory symptoms and the MD was notified and treatment given, there was again no documentation of representative notification. The DON confirmed expectations and facility policies required notifying the resident’s representative and documenting these contacts, and one nurse admitted she did not know she had to report the fever.
A resident with schizophrenia, depression, and auditory hallucinations, whose care plan required monitoring and reporting of any risk of harm to others, began making new verbal threats such as “I want to hit you” toward staff about a month after admission. An LVN observed this behavior but did not document it, did not complete a Change in Condition form, did not update the care plan, and did not notify the physician, despite facility policy requiring physician notification for significant mental or psychosocial changes. Later, after the resident threw coffee toward another resident during an activity, a Change in Condition form was completed and the NP ordered transfer to a hospital, but the earlier unreported verbal threats formed the basis of the deficiency.
Failure to Notify Physician of Abnormal Blood Glucose Readings
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of abnormal blood glucose readings as ordered for a resident with type 2 diabetes mellitus, hypertension, and dementia. The resident’s care plan, dated 4/2/25, identified risk for complications and symptoms of hypoglycemia and hyperglycemia and included an intervention to obtain blood sugars as ordered and to document and notify the physician of abnormal findings. A physician’s order, dated 4/3/25 and discontinued 4/2/26, directed staff to obtain Accu-Chek blood sugar readings four times daily and to notify the provider if the blood sugar was less than 90 or greater than 350. Review of the Medication Administration Record showed multiple abnormal blood sugar readings during the ordered period that were marked with “N” for no physician notification, including low readings of 85, 74, 80, 83, 82, and 84, and high readings of 368 and 367. Interviews revealed that when “N” was documented on the MAR, the physician would not have been notified, and the Executive Director was unable to find documentation of physician notification for the low blood sugar readings. The Executive Director also stated that if the physician had been in the building at the time of an abnormal reading, the nurse would have notified the physician and documented it in a progress note, but no such documentation was found. Additionally, the Executive Director reported that the facility did not have a policy regarding call orders and physician notification.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Notify Resident Representative of Elopement and Fever
Penalty
Summary
Licensed nurses failed to notify a resident’s responsible party (RP) of significant changes in condition and status, including an elopement and a fever. The resident had dementia, bipolar disorder, a cognitive communication deficit, repeated falls, and an active order stating he was not capable of making his own health decisions, with his daughter listed as the RP and emergency contact. He also had an active order for a Wanderguard due to exit-seeking behavior. On 2/28/26, a change of condition note documented that the resident eloped from the facility sometime after he was last seen in bed at 4:00 a.m. and was found by police at a baseball field across from the facility and returned around 5:00 a.m. The note also indicated the Wanderguard was in place but did not alarm when the resident exited. There was no documentation that the RP was notified of this elopement. On 3/1/26, a progress note documented by a licensed nurse indicated a change of condition for fever, with the resident noted to be sneezing and congested, and temperatures of 100.4°F and later 101.1°F recorded, with acetaminophen administered and the MD notified for congestion medicine. There was no documented evidence that the RP was notified of the fever. In an interview, the RP stated she was not informed by the facility of the elopement and learned of it from a friend who heard the resident’s name on a dispatch call, and she later observed new coughing when visiting the resident. The DON stated she expected licensed nurses to complete change of condition reports for elopement and fever and to notify the RP, and confirmed there was no documentation of such notifications. One licensed nurse acknowledged she did not notify the RP of the fever because she did not know it was required. Facility policies on wandering/elopement and change in condition required notification of the resident’s legal representative or resident representative and documentation in the medical record when such events occurred.
Failure to Notify Physician of Resident’s New Verbal Threats and Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s new behavior of making verbal threats toward staff, as required by the resident’s care plan and the facility’s change in condition policy. The resident was admitted with schizophrenia, depression, and auditory hallucinations, and had a care plan initiated in January that directed staff to monitor, record, and report to the physician any risk of the resident harming others, including increased anger, labile mood, agitation, or thoughts of harming someone. The resident’s MDS from late January indicated moderately impaired cognition and no verbal behavioral symptoms directed toward others. However, according to an LVN, beginning about one month after admission, the resident began verbalizing “I want to hit you” to staff when he did not get what he wanted. The LVN acknowledged that this was a new threatening behavior that started in February, but there was no documentation of these verbal threats in the progress notes, no Change in Condition (CIC) form was completed, and the care plan was not updated to reflect this new behavior. The DON stated she was not aware that the resident was making verbal threats and confirmed that facility protocol required staff to create a CIC, update the care plan, and notify the physician when a resident expressed verbal threats such as “I want to hit you.” The facility’s written Change in Condition policy required the licensed nurse to notify the resident’s physician and legal representative when there is an incident involving the resident or a significant change in the resident’s mental or psychosocial status. On a later date, a CIC was completed after the resident threw coffee toward another resident during an activity, and the NP was notified and ordered transfer to a general acute care hospital for evaluation. Prior to this incident, however, the new pattern of verbal threats toward staff was not reported to the physician or documented as a change in condition, constituting the cited failure to immediately notify the physician of a significant change in the resident’s behavior.
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