Failure to Notify Family and Complete Provider Follow-Up After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide required notification of a change in condition to a resident’s representative and to adequately follow up with the primary provider after falls. Resident #3, who had multiple diagnoses including dementia, pancreatic cancer, atrial fibrillation, history of falls, and hypotension, was cognitively intact per a recent MDS with a BIMS score of 13 and required supervision or touching assistance for toileting and bathing. The resident was care planned as being at risk for falls due to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medications. On 12/31/25, the resident experienced a fall in the late morning. Documentation in the SBAR and progress notes showed that vital signs were taken, but the SBAR did not include the date and time of the vital signs, and the neurological evaluation section was marked as not clinically applicable. The SBAR indicated that the primary care clinician was notified and that there were no new orders, and that the resident herself was notified, but there was no documentation that the resident’s family or representative was notified of this fall, despite facility policy requiring such notification when a resident is involved in an accident or incident. The DON later verified that the family should have been notified of this first fall and that neurological checks were expected after this fall. Later that same day, the resident had a second, unwitnessed fall in the evening. A progress note documented that staff found the resident on the floor with a small amount of blood on the back of her head and a small raised open area that was cleansed and bandaged. The resident was able to move extremities and complained of slight ankle pain. The LPN documented that a message was left for the NP on call and for the resident’s husband, and an SBAR for this second fall showed vital signs and indicated that the primary care clinician was notified and that staff were awaiting a call back. The DON confirmed there was no documentation that the medical provider returned the call or that any follow-up occurred after the notification, even though the resident had hit her head. The DON also confirmed that the exact time of the second fall was not documented in the progress note, and that the facility’s policy requires documentation of changes in condition and timely notification of the physician and resident representative after accidents or incidents.
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