Failure to Promptly Notify Resident Representative After Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of a change in condition following a fall, as required by facility policy and resident rights. Facility policies on Resident Rights & Dignity Management and Falls Standard state that residents and/or their designated representatives must be fully informed of changes in medical or health status, including incidents and accidents, and that documentation must include who was notified and when. The Falls Standard further specifies that family is to be notified of a fall event. These policies were not followed for one sampled resident who experienced a fall with head impact. Resident #1, admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, was non-ambulatory and dependent for transfers. The resident’s Quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. On the evening of 12/27/25, CNAs reported finding the resident lying on her face on the floor next to her bed and, under the direction of an LPN, assisting her back into bed. The resident later reported that she had fallen from bed while reaching for something on the floor and had bumped her head. There was no documentation that the RR was notified at the time of the fall, and the resident did not receive assessment and treatment until the following morning. On the morning of 12/28/25, the resident informed the Wound Care Nurse that she had fallen the previous evening, hit her head on the floor, and had a raised, tender area on her right forehead. The Wound Care Nurse then notified the Unit Manager, who in turn notified the DON and Administrator. The facility’s incident report and investigation documented the fall as an unwitnessed event reported by the resident, with RR notification recorded at 9:46 AM on 12/28/25. The RR stated she was not notified of the fall until after 9:30 AM the following morning and expressed disapproval and disappointment with the delay, noting she observed swelling on the resident’s forehead. The Administrator confirmed there was no documentation of RR notification on the date of the fall, establishing that the facility failed to promptly notify the RR of the resident’s change in condition as required by policy and resident rights.
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