F0580

D

Failure to Document Family Notification After Resident Falls

Muskego, Wisconsin Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document family notification, or the resident’s wishes regarding such notification, after two of four falls experienced by one resident. The resident was admitted with osteomyelitis of the left foot, diabetic foot ulcers, and Parkinson’s disease, and had a BIMS score of 12/15, indicating moderately impaired cognition. The resident’s fall care plan, initiated due to Parkinson’s disease, weakness, non–weight-bearing status on the left lower extremity, and forgetfulness, identified the resident as being at risk for falls, accidents, and incidents. Despite this, documentation in the EMR did not reflect that the resident was asked whether he wanted his family notified following certain fall events.

Review of the EMR showed that on one date the resident reported rolling from bed while repositioning, with no injuries noted, and on another date the resident was found squatting against the bathroom wall while holding onto a bar after attempting to get onto the toilet, with assessment, neuro checks, and vital signs within normal limits and no injuries noted. In both of these IDT fall notes, there was no documentation that the resident was asked if he wanted his family updated about the falls. During interview, the DON confirmed that the resident did not have a POA and was considered his own decision-maker, and that while the son was notified of one fall and the daughter was present for another, staff did not document the resident’s wishes or family notification for the other two falls. This was inconsistent with the facility’s “Notification of Changes” policy, which requires notification of the resident’s representative, if known, for significant changes in health status, including sudden illness or accident, even for mentally competent residents.