Failure to Notify Physician and Assess Resident After Fall Results in Delayed Treatment
Summary
The facility failed to ensure that a resident's physician was notified of significant changes in the resident's condition following a fall, which required a change in treatment. A cognitively impaired resident with severe dementia, aphasia, and a cognitive communication deficit experienced a fall during a transfer when a CNA was assisting him. The resident was lowered to the ground and struck his left side on the wheelchair. The CNA involved did not report the fall to the nurse or supervisor, and another CNA who assisted in moving the resident from the floor to the wheelchair also failed to report the incident. As a result, the resident was not assessed by a licensed nurse immediately after the fall, contrary to facility policy. Following the fall, the resident began to complain of new onset pain and required increased assistance with transfers, which was not his baseline. Multiple staff members observed these changes, including increased pain during transfers and a decline in mobility, but did not report the fall or the changes in condition to nursing or administrative staff. The LPN who was notified of the pain did not report the new onset of pain to her supervisor or the nurse practitioner, nor did she administer pain medication. The resident's increased need for assistance and pain complaints continued for over 24 hours without appropriate assessment or intervention. It was only after further complaints of pain and a physical assessment by nursing staff that the nurse practitioner was notified, leading to an x-ray that revealed a displaced comminuted intertrochanteric femur fracture. The resident was then transferred to the hospital, where he received pain management and underwent surgical repair. Throughout this period, the failure to report the fall and subsequent changes in the resident's condition resulted in a significant delay in diagnosis and treatment.
Removal Plan
- All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators.
- All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD.
- Nursing staff were trained by DON or designee on proper pivot transfers for one-person assist residents. Training emphasized that if a resident is combative, staff should not transfer the resident alone and should seek assistance.
- Staff were educated by administrator, DON, or designee on the corporate policy for identifying and reporting incidents and accidents. The in-service also included the reporting process of when an incident/accident occurs.
- Staff were educated by administrator, DON, or designee that covered definitions and examples of abuse and neglect.
- Nursing Staff were educated on identifying high fall risk residents, using assistive device markers and wall indicators - Falling Star Program.
- All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member.
- Monitoring was implemented to assess and observe one-person pivot transfers conducted by the DON or designee 3 times a week for 6 weeks and monthly thereafter for 3 months.
- Monitoring was implemented to assess resident pain with interviews of a random sample of nurses 3 times a week for 6 weeks and monthly thereafter including a specific section asking residents about pain during transfers.
- Evaluation of staff knowledge, using a questionnaire, on handling incidents and accidents. Random audits conducted on 10 staff members per week for 6 weeks, followed by periodic checks.
- Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles will be conducted daily for 2 weeks, then monthly thereafter for 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple comorbidities, including HTN, was admitted on multiple ordered antihypertensive medications. Several scheduled doses of these medications were not administered, despite the drugs being available in the facility, and the resident’s BP readings were elevated, including a markedly high value later that day. There was no documentation that the physician or resident representative were notified of the missed doses or the elevated BP, contrary to facility policies requiring notification for changes in condition and withheld medications.
Two residents experienced changes in condition for which staff did not notify the attending physicians as required by orders, care plans, and facility policy. One resident with COPD and continuous O2 use had nighttime breathing difficulties and was later sent to the hospital at family request, but staff did not document vital signs, assessments, or any physician notification regarding the respiratory change or the transfer. Another resident with CHF, diabetes, and chronic kidney disease had multiple documented daily weight gains exceeding the physician-ordered threshold for notification, yet there was no record that the physician was informed of these weight changes.
Surveyors found that staff failed to notify physicians and family representatives of significant changes in condition for two residents. One resident with hypertension and a PRN order for clonidine had multiple episodes of markedly elevated SBP documented over several months, without corresponding documentation that the MD or cardiologist was notified, despite care plan directives to report significant vital sign abnormalities. The resident reported feeling his blood pressure was often too high and stated his cardiologist said abnormal readings were not being reported. Another resident with severe cognitive impairment and multiple comorbidities experienced a documented significant weight loss, but the record contained no evidence that the physician was informed, contrary to facility policy requiring MD notification of significant weight changes. Leadership staff (DON and ADON) confirmed the lack of notification documentation in both cases.
Surveyors found that the facility failed to notify the Medical Director or attending provider when two residents left Against Medical Advice, despite a policy requiring prompt provider notification for AMA discharges. One cognitively intact resident with multiple chronic conditions signed an unauthorized discharge release after staff discussed the risks and attempted to persuade the resident to stay, but the provider was never informed. In another case, a resident with significant medical diagnoses was signed out AMA by a guardian, with no documentation of provider notification. These omissions were confirmed through record review and staff and Medical Director interviews.
A resident with multiple conditions, including type II DM and acute kidney failure, had orders for scheduled Humulin insulin and routine blood glucose checks with parameters for physician notification. On a morning when the resident was lethargic, breathing heavily, slow to respond, and later became unresponsive, staff did not administer the ordered insulin despite a blood glucose of 240 and held other morning medications based on nursing judgment. A CMA reported being told by an LPN to hold insulin if the resident did not eat, and the DON confirmed medications, including insulin, were held while staff awaited a physician callback. The MD stated he was not informed that medications were held and did not recall giving such orders, and facility policies requiring documentation and prescriber notification when vital medications are withheld and immediate consultation for significant condition changes were not followed.
The facility failed to provide advance, written, and signed notification of room changes for three residents who were moved to different rooms. Each resident had significant medical conditions and required extensive ADL assistance; two had intact cognition and one had moderate cognitive impairment. Staff documented verbal discussions and agreement about the moves for two residents, and reported verbal notification for the third, but the intra-facility room change forms for all three were left unsigned by the residents or their representatives, and no written notices were issued as required by facility policy. During interviews, leadership acknowledged that only verbal notice was given and that no written documentation of the room-change notifications existed.
Failure to Notify Physician and Representative of Missed Antihypertensives and Elevated BP
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and missed medications for a resident with multiple comorbidities. The resident was admitted from the hospital with diagnoses including type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia, and had severe cognitive impairment and dependence on staff for activities of daily living. Hospital discharge orders included multiple antihypertensive medications (lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide), which were continued in the facility’s physician orders. On the evening of admission, the resident did not receive the evening doses of atenolol and hydralazine, and the following morning did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. There was no documentation that the physician or family were notified that these medications were not administered. Vital sign records showed elevated blood pressures, including readings in the 160s/80s and a later reading of 193/99, with no documentation of a morning blood pressure on the day after admission. There was no documentation that the physician was notified of the elevated blood pressure of 193/99 after the resident had not received ordered antihypertensive medications. A late-entry nursing note documented that the resident’s blood pressure was elevated, that medications had just arrived from the pharmacy, and that a family member at the bedside was concerned; however, facility records showed that the ordered antihypertensive medications were already available on hand. The DON confirmed that medications were not administered as ordered, that available medications should have been used, and that the nurse should have clarified pre-transfer medications and notified the physician and family of the missed doses and elevated blood pressure. Facility policies required notification of the physician and resident representative for changes in condition and physician notification when medications are withheld.
Failure to Notify Physicians of Resident Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians of residents’ changes in condition in a timely manner, as required by physician orders, care plans, and facility policy. For one resident with centrilobular emphysema, COPD, and essential hypertension who used continuous oxygen at three liters via nasal cannula, the care plan directed staff to monitor for and report signs of respiratory distress to the physician. On one occasion, the resident experienced trouble breathing during the night and initially refused transfer to the hospital. The DON recalled this event and stated that the resident’s daughter later convinced the resident to go to the hospital that morning. However, the medical record contained no documentation of vital signs, assessments, or any notification to the physician regarding the change in respiratory status or the subsequent hospitalization, and the DON confirmed the assigned LPN did not document the change in condition or physician notification. For a second resident admitted with diagnoses including disruption of an external surgical wound, infection following a procedure, combined systolic and diastolic CHF, type 2 diabetes with polyneuropathy, and chronic kidney disease, the care plan required monitoring and reporting to the physician of significant weight changes and changes in lung sounds, edema, shortness of breath, vital signs, and weight. A physician order directed staff to notify the physician of a weight gain of two or more pounds in one day or five pounds in one week. Weight records showed the resident gained 4.0 lbs from one day to the next on one occasion and 3.4 lbs from one day to the next on another occasion. There was no documentation in the medical record that the physician was notified of these weight gains, and the regional clinical nurse confirmed that the physician was not notified on those dates, contrary to the physician’s order and facility policy requiring notification of changes affecting the resident.
Failure to Notify Physicians and Families of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians and family representatives of residents’ changes in condition as required by policy. For one resident with diagnoses including pelvic fracture, chronic pain, PTSD, depression, epilepsy, and hypertension, the care plan directed staff to monitor vital signs and notify the medical doctor of significant abnormalities. Physician orders included clonidine 0.1 mg by mouth every 8 hours as needed for systolic blood pressure greater than 170. Vital sign records showed multiple elevated systolic blood pressures, including 171, 174, 206, and 219 over several months. Progress notes from early December through mid-March contained no documentation that the physician was notified of the elevated blood pressures on specific dates when readings were 206 and 219. The resident reported concern that his blood pressure was often too high and stated that his cardiologist had informed him that no one from the facility was reporting abnormal blood pressure readings. The DON confirmed there was no documentation of notification to the primary physician or cardiologist regarding these high blood pressures. The deficiency also includes failure to notify the physician of a significant weight loss for another resident with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, who had severe cognitive impairment and was dependent on staff for activities of daily living. A weight loss note documented that this resident’s weight decreased from 241 pounds to 183.7 pounds over several months, constituting a significant weight loss. The medical record did not contain documentation that the physician was notified of this significant weight loss. The ADON confirmed the absence of documentation supporting physician notification. Facility policy on impaired nutrition and unplanned weight loss required staff to report any significant weight gains or losses or abrupt or persistent changes from baseline appetite or food intake to the physician. This deficiency was investigated under a specific complaint number.
Plan Of Correction
This plan of correction constitutes a written allegation of substantial compliance with federal Medicare and Medicaid Requirements. Submission of this plan of correction does not constitute an agreement that the deficiencies actually exist, nor is it an admission that they existed. This submission is a good-faith expression of the facility's desire to fully comply with Medicare and Medicaid requirements. F580 Notify of changes The PoC will determine what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #24 continues to be monitored for blood pressure as ordered, and the physician, cardiologist, and resident have been notified of the ongoing results per ADON beginning 3-24-26. Resident #24 was assessed by the DON for any negative effects on 4-9-26, and none were identified. Resident # 51 is no longer in the facility. How will you identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? All residents in the building who have a change in condition could be affected by this practice. A sweep of residents on 3-28-26 by Nursing managers identified that the MD and the responsible party had been called to the physician and family by the MDS nurse starting 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur The DON/Designee educated all nursing staff by 4-9-2026, to notify physicians and responsible parties of any changes in conditions. The weekly Nutrition at Risk meeting results were called to the physician and family by the MDS nurse starting 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur The DON/Designee educated all nursing staff by 4-9-2026, to notify physicians and responsible parties of any change in condition, including parameters set by the physician. Weekly/ monthly weights are discussed in the weekly nutrition at Risk meeting and MDS nurse/designee was trained by DON on 3-31-36 to notify significant changes to MD and family/resident. Corrective actions will be monitored to ensure the deficient practice will not recur. During daily morning clinical and standdown the DON/designee reviews all progress notes, labs, and assessments and verifies that the physician and responsible part is notified of any change in condition, significant weight loss or gains and abnormal results identified with established parameters. DON/designee audit 5x w X 4 weeks with results submitted to QAPI committee weekly.If any concerns are identified with the audits the issue is immediately corrected (notifications completed) and parties involved reeducated.
Failure to Notify Provider of Residents Leaving Against Medical Advice
Penalty
Summary
The deficiency involves the facility’s failure to notify the Medical Director or attending provider when residents left the facility Against Medical Advice (AMA), contrary to facility policy. For one resident admitted with diagnoses including chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed the resident was discharged AMA. The most recent MDS indicated moderately impaired cognition with varying levels of assistance needed for ADLs, and a reassessment on the day of discharge documented a BIMS score of 13, indicating the resident was cognitively intact. An "Unauthorized Discharge Release of Responsibility" form dated the day of discharge showed the resident signed out AMA and that staff discussed the risks of leaving and attempted to get the resident to stay. However, interviews with the Regional Clinical Director and the Medical Director confirmed that the Medical Director/provider was not notified of this AMA discharge. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential hypertension, was also discharged AMA. The most recent MDS showed the resident was independent with eating but dependent on staff for toileting and bathing and required partial assistance with personal hygiene. A progress note documented that this resident was signed out AMA by the resident’s Guardian. Review of the medical record revealed no documentation that the Medical Director/provider was notified when this resident left AMA, and the Regional Clinical Director confirmed that no such notification occurred. Facility policy titled "Discharging a Resident Without a Physician's Approval" required that the attending physician or provider be promptly notified when a resident or representative requests discharge AMA, but this notification did not occur for these two residents.
Failure to Notify Physician and Improperly Holding Ordered Medications After Resident Status Change
Penalty
Summary
The deficiency involves the facility’s failure to timely notify the physician of a significant change in condition and failure to notify the physician when ordered medications, including insulin, were independently held. A resident with diagnoses including hypervolemia, orthostatic hypotension, hypertension, dehydration, acute kidney failure, type II diabetes, anxiety, and depression was admitted on 12/11/25 and had physician orders for Humulin insulin twice daily and blood glucose checks before meals and at bedtime, with instructions to notify the physician for blood glucose levels over 400 or under 70. On the morning of 12/18/25, the resident’s blood glucose was 240 at 7:30 A.M., but the ordered Humulin at 8:00 A.M. was not administered. Nurse documentation indicated the resident was lethargic, breathing heavily, and slow to respond, and that the physician was called and the nurse was waiting for a response, but there was no documentation of any physician order to hold medications, including insulin. Later that morning, the resident became unresponsive, with a blood pressure of 70/30, blood glucose of 182, and respirations of 30 per minute, and EMS was called after another attempt to contact the physician without a return call. The Medical Director stated he was not informed that medications were held and did not recall giving any order to hold the resident’s medications, including insulin, and clarified he would only hold fast-acting insulin, not long-acting insulin. A CMA reported being instructed by an LPN to hold insulin if the resident did not eat breakfast, and stated the resident was not awake that morning. The LPN confirmed instructing the CMA to hold insulin if the resident did not eat, based on nursing judgment, and reported sending a message to the physician without receiving a response. The DON stated the nurse called the physician and waited for a call back, and that the CMA held morning medications, including insulin, per nursing judgment. Facility policies required explanatory notes when regularly scheduled medications are withheld and prescriber notification when vital medications are withheld, and required immediate consultation with the physician and notification of the resident representative for significant changes or deterioration in health, which did not occur as required in this case.
Failure to Provide Required Written Notice for Resident Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide advance, written notification of room changes, signed by the resident or their representative, for three residents who experienced intra-facility room moves. Facility policy required that, prior to making a room or roommate change, residents and their representatives receive advance written notice in a language and manner they understand, including the reasons for the move. For one resident admitted with COPD, chronic respiratory failure, and obesity, with intact cognition and extensive ADL assistance needs, a progress note documented that staff discussed a room move with the resident and her daughter and that they agreed; however, the intra-facility room change form dated the following day was not signed by the resident or her representative. A second resident, admitted with hypertensive chronic kidney disease, GERD, and obesity, had moderate cognitive impairment and required extensive ADL assistance. A progress note documented that this resident was informed of a room move, agreed to it, and was observed telling others about the move, but the corresponding intra-facility room change form was not signed by the resident or a representative. A third resident, admitted with limb girdle muscular dystrophy, neuromuscular bladder, and osteoarthritis, had intact cognition and extensive ADL assistance needs. For this resident, there were no progress notes documenting a discussion of the room change, and the intra-facility room change form was also unsigned by the resident or representative. During interviews, the social worker and administrator confirmed that room changes occurred for all three residents, that no written notice of the transfer was given, and that they believed 24-hour verbal notice was appropriate, which did not meet the facility’s written-notice requirement.
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