Failure to Notify Family of Resident’s Significant Bruising and Possible Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition, specifically the development and worsening of a large bruised area on the resident’s back. A family member reported that they first observed the large bruise when the resident was admitted to the hospital on 12/21/25 and stated they had not been informed of the bruise or of any fall. The resident told the family member that about a week prior to the hospital admission, she had a fall during a transfer with staff. Review of the clinical record showed no documentation that the resident had a fall. The resident’s admission MDS, dated 9/24/25, indicated the resident was cognitively intact and able to make consistent and reasonable daily decisions. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and had increased in size. An event was opened to ensure the wound nurse was aware, and the Nurse Practitioner was notified. However, the documentation did not show that the resident’s family had been notified of this change in condition. During an interview, the DNS explained that when an event was created in the computer, it was turned into an internal incident report, and no further information or documentation of family notification was provided. The facility’s notification policy stated that the resident’s responsible party would be notified immediately of a change in condition, but this was not reflected in the record for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.