Failure to Notify Physician and Family After Unexplained Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family after an injury of unknown origin was identified. The resident, who had diagnoses including Alzheimer’s disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, had a quarterly MDS showing severe cognitive impairment and required partial to moderate assistance with toilet hygiene, transfer, and bed mobility. A care plan identified the resident as high risk for falls related to lack of safety awareness. On 1/10/26 around midday, the resident’s wife visited the memory care unit and found the resident with a swollen, darkly bruised left eye. She reported that staff told her they did not know why he had a black eye and that she had not received any call from the facility about the injury. She also stated that staff had not planned any X‑ray or test to fully assess the injury and that staff were dismissive of her concerns. On observation on 1/15/26, the resident was seen in a common area with a visibly swollen and discolored left eye. A general progress note dated 1/10/26 documented that the resident’s left eye was puffed and dark in color and that staff would continue to monitor, but the clinical record contained no documentation that the physician, appropriate personnel, or the resident’s spouse were notified of the black eye. The DON, who was covering for the Administrator, reported he was not informed of the injury until 1/12/26 and did not know who first discovered it. He acknowledged that no assessments or interviews were completed on 1/12/26 or 1/13/26 and that the incident had not been reported to proper personnel or thoroughly investigated. The facility’s Incident/Accident Reporting policy required staff to notify the physician and document the notification in the medical record when an unexplained injury such as a bruise is identified, which was not done in this case.
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