Failure to Notify Physician of Resident’s New Fracture and Treatment After Hospital Readmission
Penalty
Summary
The facility failed to immediately notify a resident’s primary care physician of a change in condition and treatment following the resident’s return from a General Acute Care Hospital (GACH). The resident, who had type 2 diabetes mellitus and dementia with severely impaired cognition, was dependent for toileting, lower body dressing, and footwear. According to the electronic medical record progress note dated 12/27/2025 at 22:25, the resident returned from the hospital via ambulance with a right arm splint and sling due to a right elbow fracture. The GACH after-visit summary documented a new diagnosis of a radius fracture and right elbow joint pain, with discharge instructions for a follow-up orthopedic appointment and a nursing communication order for application of a right posterior long arm splint. Record review showed there was no documentation that the attending physician was notified of the resident’s readmission, the new elbow fracture diagnosis, or the presence of the right arm device. During interview, the DON stated that all licensed nurses are expected to notify the physician when residents are readmitted from the hospital or when there is a change of condition, and confirmed there was no such documentation in the resident’s progress notes. The treatment nurse reported that she did not notify the physician about the right arm device because she forgot. The facility’s policy titled “Admission Assessment and Follow up: Role of the Nurse,” revised 01/2025, requires contacting the attending physician to communicate and review findings of the initial assessment and other pertinent information and to obtain admission orders based on these findings.
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