Failure to Notify Resident Representative After Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition following a fall. A male resident with multiple complex diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, was admitted with moderate cognitive impairment as evidenced by a BIMS score of 09. His care plan, initiated 12/31/2025, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion. An incident report dated 01/17/2026 at 9:00 p.m., completed by LVN A, documented that the resident was found on the floor near the nurses’ station after he slipped. The report noted that vital signs, neuro checks, and blood sugar were obtained, glucose was given, and his post-treatment blood glucose was 118, and that he was ambulatory without assistance. The incident report section for agencies/people notified reflected “No Notifications found,” and review of the resident’s progress notes for 01/17/2026 showed no evidence that the resident’s family was notified of the fall. The resident’s face sheet listed a responsible party, and facility policy stated that residents have the right to be notified of their medical condition and any changes in condition, and to be informed of and participate in care planning and treatment, including through a legal representative appointed in accordance with state law. During an interview on 01/27/2026 at 10:40 a.m., the resident’s family reported they were not notified of the fall and only learned of it the following day when visiting. This sequence of events formed the basis for the cited deficiency related to failure to inform the resident’s representative of a change in condition.
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