Failure to Provide Timely Emergency Care After Resident Fall
Summary
A resident with a history of a recently repaired right hip fracture and severe cognitive impairment experienced an unwitnessed fall in the facility's bathroom. Following the fall, the resident reported pain in the right hip and required increased assistance with transfers, as documented by both nursing and CNA staff. Despite these changes, the nurse on duty faxed the physician rather than arranging for immediate evaluation or emergency care, and the resident was assisted back to bed by two CNAs. Over the following days, the resident continued to report significant pain, demonstrated by high pain scores and increased need for pain medication, and required two-person assistance for transfers, which was a change from his previous baseline. Multiple staff members, including CNAs and nurses, observed and reported the resident's increased pain and decreased mobility to the nursing leadership. Documentation shows that the resident received PRN Tylenol for pain on several occasions, but the pain persisted and even escalated to severe levels. Despite these ongoing symptoms and the resident's inability to bear weight, the facility did not send the resident for emergency evaluation until several days after the initial fall. The delay in intervention occurred even though staff interviews revealed that several team members believed the resident should have been sent to the hospital earlier due to his change in condition. When the resident was finally sent to the emergency room, he was found to have a new pelvic fracture, hypoxia, and COVID-19. The facility's own policy required staff to respond properly to incidents affecting resident well-being, but the response to this resident's change in condition was not timely. Interviews with staff and nursing leadership confirmed that the resident should have been sent for emergency evaluation earlier, given the clear change in his condition and increased care needs following the fall.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident on blood thinners experienced a fall that reopened an existing wound, but the LPN on duty did not perform neurochecks or immediately notify a provider, instead documenting the event in a communication book for review the next day due to lack of on-call coverage. The next morning, an RN reported the resident had a severe headache and altered cognition and expressed concern for a possible brain bleed, confirming that neurochecks and timely provider notification had not occurred. Later, frank blood was noted in the toilet without immediate physician notification, despite the DON’s expectation that such findings, along with the resident’s anticoagulant use and cognitive impairment, should trigger neurochecks, prompt provider contact, and possible ED transfer. The DON and RN reported that the facility had not maintained 24-hour on-call physician services for several years, contrary to facility policy requiring continuous physician availability for emergencies.
Staff could not reliably contact the Medical Director or confirm physician coverage for residents when he was on vacation. An LPN reported long-standing difficulty reaching the physician, the DON and Administrator were unsure who was covering, and a posted notice directed staff to send issues to the ED and stated no scripts would be available. Interviews and the facility policy showed the Medical Director was expected to oversee resident care when attending physicians were not available.
A resident with a critically low potassium level had a lab result communicated to nursing staff overnight, but repeated attempts to reach the on-call physician were unsuccessful. Nursing staff did not escalate the issue to the medical director or backup provider, and the attending physician was not made aware of the critical result. Facility policy and expectations for 24-hour physician coverage were not met.
A resident with ALS, diabetes, and depression experienced cough, congestion, and fear of choking overnight. The nurse notified the physician by text about some symptoms but did not communicate the resident's fear of choking or shortness of breath. The physician did not respond for over eight hours, and the nurse did not escalate the issue to the DON or Medical Director as required by policy. The resident's family later called 911, and the resident was hospitalized with pneumonia and hypoxia.
A resident experiencing abdominal pain and emesis was assessed by an LPN, who attempted to contact the on-call physician via telehealth but did not receive a timely response. While waiting for a callback, the resident's representative was informed and transported the resident to the ER without a physician's order. The resident was later admitted to the hospital for bowel obstruction and hypotension. The facility administrator acknowledged the on-call provider did not respond in a reasonable timeframe.
A resident with a complex medical history, including TBI, hydrocephalus with shunt, tracheostomy, and quadriplegia, experienced a fall and subsequent decline in condition. Nursing staff were unable to reach the assigned physician for over four hours despite multiple attempts, and did not transport the resident to the ER in a timely manner. The physician was eventually reached and instructed staff to send the resident to the ER, resulting in a delayed transfer.
Failure to Provide 24-Hour On-Call Physician Coverage and Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide or arrange 24-hour on-call physician services and to ensure timely provider notification and appropriate post-fall assessment for a resident on blood-thinning medication. After the resident, who was new to the facility and taking blood thinners, fell at 7:15 p.m. on 2/4/26, an LPN assessed the resident, noted that an existing wound on the resident’s bottom had reopened, and applied a dressing. However, neurochecks were not performed, and the provider was not notified immediately. Instead, the LPN documented the fall in a communication book for the provider to review during rounds the next day, stating that there was no on-call provider available. The facility’s own policy required 24-hour physician coverage for emergencies, including contacting the primary physician first, then the on-call physician, and, if necessary, the medical director, and transporting the resident to the ED if no physician was reachable and immediate assessment was required. On the following morning, an RN caring for the same resident reported that the resident requested transfer to the ED for a headache rated 7/10 and expressed concern for a possible brain bleed due to the recent fall, use of blood thinners, and altered cognition. The RN confirmed that neurochecks had not been performed after the fall and that the provider had not been notified immediately. The DON stated that, per facility expectations, staff should assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management after a fall, and confirmed that these steps were not followed for this resident, who also had moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was observed in the toilet, but staff still did not notify the physician immediately, despite the DON’s statement that this finding should have prompted an ED transfer due to increased risk of bleeding and that normal vital signs alone could not rule out internal bleeding. The DON and RN both confirmed that the facility had not had 24-hour on-call physician coverage for the past four years, and local providers did not round at the facility, have access to records, or provide on-call coverage, affecting all residents.
Physician Coverage Not Available for Resident Care
Penalty
Summary
The facility failed to ensure a physician was overseeing the care of all residents when the Medical Director was unavailable and staff could not reliably contact a covering provider. A resident roster dated 11/22/25 showed 36 residents in the facility. On 11/22/25, surveyors observed a posted notice at the nursing station stating the Medical Director was on vacation from 11/20/25 to 12/1/25 and directing staff not to call or text him, but instead to call the office number. A handwritten note on the posting stated that no one answered at that number or its extensions, there was no option to leave a message except with billing, and that the Administrator and DON were aware and unsure of the situation. The note also instructed staff to send issues to the ED and stated there would not be any scripts available. Interviews confirmed staff did not have effective access to a physician. An LPN said it had been an impossibility for a very long time to contact the physician and that there was no one covering that she knew of, adding that if she needed a physician she did not know what she could do. The Administrator said she did not know if the Medical Director was the physician for all residents or whether anyone was covering while he was on vacation. The Medical Director’s nursing home coordinator later said he was still taking call and that if staff could not reach him, the Administrator could contact her and she could reach him, but also stated the posted note was incorrect and should have indicated an NP would cover during the day. Other nurses reported they could not get ahold of the Medical Director or leave messages, and the facility policy stated the Medical Director was to be available to oversee the medical care of all residents when other attending physicians were not available.
Failure to Provide 24-Hour On-Call Physician Services for Critical Lab Result
Penalty
Summary
Facility staff failed to provide 24-hour on-call physician services for one resident when a critical laboratory result was received. The resident had a potassium level of 2.9 mEq/L, which is below the normal range. Nursing staff documented that they attempted to contact the on-call physician multiple times during the early morning hours, but did not receive a return call. The progress notes indicate that the on-call physician was not reached despite repeated attempts, and the issue was not escalated to the medical director or backup provider as per facility expectations. Interviews with administrative and clinical staff confirmed that nurses are expected to reach an on-call physician at all times and should escalate to the medical director if unable to do so. The attending physician stated that there is always a backup provider available and that the on-call service has their contact information. He also confirmed he was not made aware of the resident's critical potassium level and would have ordered immediate treatment if notified. No additional documentation or policy regarding 24-hour physician coverage was provided prior to the survey exit.
Failure to Ensure Timely Physician Response to Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician responded in a timely manner to a resident's change of condition. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, began experiencing symptoms such as headache, cough, congestion, and expressed fear of choking during the night shift. The resident was cognitively intact and able to communicate his symptoms and concerns, including shortness of breath and anxiety about lying down due to fear of choking. The nurse on duty administered medications for headache and sore throat, and documented the resident's complaints, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent text messages to the resident's physician at two points during the night shift, but the physician did not respond until over eight hours later, after the shift had ended. The nurse did not escalate the situation by contacting the Director of Nursing (DON) or the Medical Director when the physician failed to respond, as required by facility policy. The resident continued to experience symptoms and anxiety throughout the night, remaining upright to ease breathing, and felt that the nursing staff did not believe the severity of his symptoms. The following morning, the resident's family called 911, and the resident was transferred to a general acute care hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Interviews with the resident, the nurse, the physician, and the DON confirmed that the physician was not informed of the full extent of the resident's symptoms, particularly the fear of choking and shortness of breath. The physician stated that he would have ordered additional interventions if he had been made aware of these symptoms. Facility policy required immediate escalation to the DON or Medical Director if the attending physician could not be reached, but this was not done. Documentation and interviews confirmed the delay in physician response and the lack of appropriate escalation.
Failure to Ensure 24-Hour Physician Availability for Emergency Care
Penalty
Summary
The facility failed to ensure the provision of physician services 24 hours a day in the event of an emergency for one resident. On the evening in question, a resident complained of severe abdominal pain and emesis, and the nurse on duty assessed the resident, determining that the resident was not in distress at that time. The nurse attempted to contact the on-call physician through the telehealth service but did not receive a timely response after calling twice. While waiting for a response, the resident's representative was informed of the situation and ultimately transported the resident to the emergency room without a physician's order, as the nurse was still awaiting a callback from the practitioner. Documentation in the medical record indicated that the resident was later admitted to the hospital for a bowel obstruction and hypotension. Staff interviews confirmed that the nurse took the resident's complaint seriously and followed protocol by attempting to contact the on-call provider, but the lack of timely physician response led to the resident being transported by the representative. The facility administrator acknowledged that the on-call practitioner should have been available and responded in a reasonable timeframe.
Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.