Failure to Notify Physician by Phone After Resident Head Injury
Penalty
Summary
The facility failed to promptly notify a resident’s physician by phone of a head injury following a fall, as required by its own fall prevention and management policy. The policy, revised 10/14/25, stated that for residents with suspected head injury, physicians should be notified by phone and not fax. The resident involved had diagnoses including Alzheimer’s disease, dementia, and repeated falls, and a care plan identifying falls and gait/balance problems. On 12/06/25 at 6:40 a.m., progress notes documented that the resident came to the nursing station stating she had fallen in her room, hit her head, and had “another knot” on the back of her head; assessment found a knot with bruising to the right back of the head, and staff sent a fax to the physician. Later that day at 2:07 p.m., documentation showed the physician was notified by email with information that neurological checks and vital signs were stable, and on 12/09/25, the physician was informed the resident had eight falls since 10/07/25, six of them since 11/20/25. During interview, an administrative staff member confirmed the facility did not notify the physician by phone regarding the 12/06/25 head injury, contrary to facility policy. This sequence of events, including the resident’s documented fall history, the identified head injury with bruising, and the use of fax and email instead of a phone call, formed the basis for the deficiency related to failure to notify the physician as required.
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