F0580

D

Failure to Notify Legal Guardian of Resident Fall and Hospital Transfer

Chicago, Illinois Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s state-appointed legal guardian of a fall, associated hospital transfer, and subsequent return, despite clear documentation that the guardian was the resident’s primary surrogate decision maker. The resident was admitted from an acute care hospital with diagnoses including dementia without behavioral disturbance, difficulty in walking, lack of coordination, dysphagia, protein-calorie malnutrition, dehydration, muscle weakness, hypertensive heart disease, iron deficiency, and adult failure to thrive. The care plan, initiated in late December, documented that the resident had a surrogate decision maker and, as of the end of March, a state-appointed guardian, with instructions to contact the adult guardianship division. A social worker’s progress note on 3/31/2025 recorded that the resident had been appointed a public guardian and included the guardian’s information, and a letter from the county public guardian’s office directed that staff must notify the appointed guardian in the event of an emergency and that compliance with this procedure was mandatory.

On the night of 4/8/2025, the resident experienced a fall in the bathroom. An LPN (V7) later recalled responding to a call light and finding the resident lying on the left side on the bathroom floor; the resident did not remember what happened after standing up from using the bathroom. The LPN observed a minimal skin tear on the left eyebrow, cleaned the area, and applied a gauze dressing. Progress notes dated 4/9/2025 at 2:10 AM documented that the resident was sent to the emergency room, but there was no documentation that the legal guardian was notified of the fall or the transfer. A subsequent progress note at 2:19 AM documented that the LPN left a voice message with the resident’s second emergency contact about the fall and the hospital observation, again with no documentation that the legal guardian was notified.

Additional progress notes on 4/9/2025 at 6:12 AM and 6:40 AM, documented by another LPN (V18), recorded that the hospital reported a negative CT scan, that the resident was on the way back to the facility, and that the resident returned from the hospital with no new orders, an alteration of skin to the left eyebrow without redness or swelling, no pain, and stable vital signs, with safety measures maintained. These notes did not document any notification to the legal guardian regarding the resident’s updated status or the fall incident. A facility fall incident description form for the 4/8/2025 fall showed that a family member was notified the following morning, but did not show that the legal guardian was notified. Multiple staff interviews, including with LPNs, unit managers, the social work director, and the DON, confirmed that facility practice and policy required that a legal guardian, when present, be notified first of falls, changes in condition, and hospital transfers, and that such notifications be documented in the resident’s chart. Staff acknowledged that in this case the legal guardian should have been notified and that the notification was not documented, confirming the failure to follow facility policy and the guardian’s instructions regarding notification.

Interviews with involved nursing staff further clarified the inaction. The LPN who documented the fall and hospital transfer (V7) stated that if a resident has a POA or legal guardian on file, that person should be notified of any changes and again when the resident returns from the hospital, with the conversation documented. When presented with the admission record and progress notes, this LPN acknowledged that the legal guardian should have been contacted and that the chart only showed a message left for the second emergency contact. Another LPN (V18), who documented the resident’s return from the hospital, stated that if the progress notes showed the resident came back from the hospital, the legal guardian should have been notified, but was unsure whether such notification occurred and confirmed that it was not documented. The DON and other managers reiterated that the legal guardian should always be notified first and that documentation of attempts or messages was required, underscoring that the facility did not follow its own notification policy or the public guardian’s written instructions for this resident’s 4/8/2025 fall and related events.