Failure to Notify Family of Resident Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member after the resident experienced a fall. The resident’s admission record listed the daughter as the first emergency contact and the son as the second emergency contact. The resident’s MDS dated 10/21/25 documented a BIMS score of 4, indicating severely impaired cognition. A nursing note dated 12/1/25 at 6:04 a.m. recorded that the resident was found on the bathroom floor and that the nurse practitioner and DON were notified. However, there was no documentation in the progress notes that the resident’s family was notified of the fall. During review of the facility’s TRIPS form for the fall dated 12/1/25, the section for family notification was marked “NA,” and the DON stated she did not know what “NA” meant in that context. The facility’s policy titled “Change in a Resident’s Condition or Status,” approved 9/2/15, requires licensed staff to promptly notify the resident, attending physician, and family/representative of changes in the resident’s condition or status, including when the resident is involved in any accident. Despite this policy, there was no evidence that the resident’s family or representative was notified following the fall incident, resulting in the cited deficiency.
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