Failure to Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to assess, monitor, and notify the physician regarding an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had a history of cerebral infarction, aphasia, vascular dementia with behavioral disturbance, and anxiety disorder, was admitted to the facility in 2016. On January 8, 2025, a nurse's aide and a therapist observed discoloration and bruising around the resident's left eye and forehead, but there was no documentation of a fall or injury in the facility records. The resident was later transferred to a local hospital for a new onset of strabismus in the left eye, where it was reported that the resident had an unwitnessed fall with a head injury. Despite the observations made by the staff, there was no documented evidence that the physician was notified of the resident's condition. The facility's policy required that changes in a resident's condition be assessed and communicated to the physician, but this was not done. Interviews with staff confirmed that the discoloration was observed, but the necessary steps to document and report the injury were not followed, leading to a deficiency in the quality of care provided to the resident.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. F-0684 SS-D QUALITY OF CARE The facility can not retroactively correct the cited deficient practice for Resident R1. Initial audit to be conducted with 7 day look back of progress notes to identify residents with injuries of unknown origin were assessed, monitored and physicians notified. NPE or designee will educate licensed nursing staff on assessing, monitoring and notifying physicians with injuries of unknown origin. DON or designee will conduct random weekly audits of progress notes (5 residents) x 4, then monthly x 2 for residents with injuries of unknown origin to ensure they are assessed, monitored and physicians notified. Results of the audits will be reported at the monthly Quality Assurance Performance Improvement Meetings for review and recommendations.