F0580

G

Failure to Notify Physician of Resident’s Significant Change in Condition After Fall

Jackson, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident following an unwitnessed fall, resulting in a left hip fracture going undiagnosed for six days. The resident had a history of bilateral primary osteoarthritis of the left hip and vascular dementia and had been functioning with improving mobility in PT and OT prior to the fall. On the morning of the fall, nursing documentation showed the resident was found on the floor lying on the left side, reported left hip pain at 5/10 with sharp, painful-to-touch discomfort, and had some decreased ability to move the left leg. The nurse notified the physician of the fall and pain, and the physician ordered PRN Norco for moderate to severe pain. The physician later, on a follow-up visit, ordered a routine x-ray of both hips and pelvis and therapy reassessment, with the x-ray appointment scheduled for a later date.

In the days following the fall, multiple clinical records documented a marked and ongoing decline in the resident’s mobility and persistent moderate to severe pain with movement, but there was no documentation that these changes were communicated to the physician. PT notes from 2/2 through 2/5 recorded that the resident complained of 10/10 pain with movement of the left lower extremity, was unable to ambulate, could not bear weight on the left leg, and required increasing assistance for bed mobility and positioning, with pain at rest remaining low but pain with movement consistently at 9–10/10. OT notes over the same period documented that the resident repeatedly reported 10/10 pain, refused or was unable to participate in weight-bearing activities, and that left lower extremity pain significantly impacted the ability to perform transfers, toileting, and ADLs, limiting therapy to in-chair ADLs and upper extremity strengthening. Therapy staff confirmed that prior to the fall the resident could fully straighten the left leg, had full ROM, and ambulated 50–60 feet with a FWW and contact guard, but after the fall could not walk, bear weight, extend or move the left leg, or roll in bed without severe pain, and that this information was not documented as being communicated to licensed nurses or the physician.

Nursing and CNA interviews further described unreported changes in the resident’s condition. CNAs stated that after the fall the resident was in “quite a bit of pain,” could no longer roll in bed as before, required two CNAs for bed mobility instead of one, could not fully extend the left leg, and cried out in pain and said “please, no” during incontinent care and repositioning; these changes were reported to a licensed nurse. The MAR showed a significant increase in the use of Norco for pain scores ranging from 5/10 to 8/10 after the fall. Progress notes from 1/31 through 2/6 contained no evidence that the physician was notified of the resident’s ongoing severe pain with movement, inability to move in bed, stand to transfer, bear weight, or ambulate. The nurse later acknowledged suspecting a possible dislocation or fracture based on the resident’s increased pain and inability to straighten the leg, and confirmed that therapy and CNAs had reported moderate to severe pain and decreased mobility, but he did not report these ongoing issues to the physician because the PRN Norco was effective in reducing pain and an x-ray was already scheduled. The physician stated he was not informed of the resident’s inability to bear weight, transfer, roll in bed, or walk after the initial report and that he ordered the x-ray as routine based on the limited information provided. The DON confirmed there was no documentation that the resident’s mobility declines and prolonged moderate to severe pain were communicated to the physician, despite facility policies requiring assessment and reporting of signs such as pain, decreased mobility, and other acute condition changes for physician evaluation and management.

On 2/6, when the x-ray was finally completed at the acute care hospital, it showed a new left hip fracture. The PT and OT discharge summaries documented a clear decline from baseline and from the functional status on 2/1 to the time of transfer, including progression from minimal or contact guard assistance to maximum assistance for bed mobility, transfers, and functional mobility during ADLs, and the inability to ambulate due to safety concerns. The DON stated that these signs and symptoms—pain, decreased mobility, and functional decline—should have been considered a change of condition and reported to the physician, and confirmed that the lack of such reporting delayed the diagnosis and treatment of the resident’s left hip fracture and caused the resident to experience continued declines in mobility and unneeded pain and suffering.