Failure to Promptly Notify Physician of New Onset Knee Pain After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician and ensure appropriate follow-up when a resident reported new onset left knee pain and functional changes following a fall. The resident, who had a history of osteoarthritis, prior bilateral knee surgeries, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities, was initially admitted on an unspecified date. Her MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for assistance with ADLs including toileting, showering, dressing, and supervision or touching assistance for walking. Her care plan for arthritis, initiated 4/1/2025, directed staff to monitor, document, and report to the physician signs and symptoms such as joint pain, stiffness, swelling, decline in mobility or self-care, contracture formation, joint shape changes, crepitus, and pain after exercise or weight bearing. On 10/9/2025, a change of condition note documented that the resident was found sitting on the floor by her bed after losing her balance while returning from the restroom, indicating a fall event. On 10/12/2025, three days after the fall, licensed nursing staff were made aware of the resident’s report of new onset left knee pain and limited range of motion, but the facility did not ensure confirmation of physician notification. On 1/24/2026, the resident again complained of left knee pain accompanied by a popping noise, yet there was no confirmation that the physician had been notified at that time. During interviews, the resident reported that she had undergone two prior knee surgeries, felt that metal hardware was moving in her knee, and stated that her pain had not been effectively managed for three months. During an observation and interview on 1/27/2026, the Director of Rehabilitation examined the resident’s knee, noted a clicking consistent with crepitus, and the resident reported that the popping noise had worsened since the fall and that she had consistently reported the popping and pain to nursing and rehabilitation staff. These documented inactions and lack of confirmed physician notification and follow-up constituted the cited deficiency.
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