F0580

D

Failure to Notify Physician of Fall and Hospital Transfer

Dekalb, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the resident’s physician of a fall and subsequent hospital transfer as required by its Significant Condition Change and Notification policy. A male resident with a history of left femur fracture, weakness, history of falls, cognitive communication deficit, and adjustment disorder experienced a fall in the bathroom while being assisted by a CNA. The fall incident report documented that the ADON was notified, but did not show that the resident’s primary care physician was notified. A health status note described the circumstances of the fall and stated that the power of attorney and a nurse practitioner were notified, but did not specify which practitioner, the method or timing of notification, the number of attempts made, or the practitioner’s response. The RN who assessed the resident after the fall reported no apparent injuries and no complaints of pain at that time.

The resident’s physician later documented that the resident reported a fall that had occurred approximately two days prior to the physician’s evaluation, and the physician stated he had not been notified by the facility of the fall on the day it occurred. The physician also reported he was not notified of the resident’s subsequent hospital transfer after x-rays revealed a fracture. Review of the medical record showed a hospital transfer form listing this physician as the primary care physician, but no progress note indicating that he was informed of the resident leaving the facility or being transferred to the hospital. The facility’s policy required that the medical practitioner be contacted for accidents or incidents with potential need for practitioner intervention, with each attempt charted, but the documentation and interviews showed that this did not occur for this resident’s fall and hospital transfer.