Failure to Notify Resident Representative After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in condition following a fall. The resident, who had a traumatic subarachnoid hemorrhage after a motor vehicle accident, was admitted with severe cognitive impairment. A BIMS assessment dated January 17, 2025, showed severe cognitive impairment, and physician orders dated February 5, 2025, documented that the resident did not have capacity to make his own decisions. On February 5, 2026, the Administrator confirmed that the resident’s representative was responsible for making healthcare decisions due to the resident’s severe cognitive impairment. The facility’s policy on Changes in Resident Condition states that the resident’s representative is to be notified when changes in condition occur, including accidents involving the resident that result in injury and may require physician intervention. On May 16, 2025, at 1:10 a.m., an SBAR for change of condition documented that the resident had an unwitnessed fall and was found on the floor next to his bed, with a notation to notify the MD and call the representative in the morning. Risk Meeting Notes from later that morning, attended by the DON, recorded that the resident was status post fall with injury and specifically indicated that the resident representative was not notified. A review of the progress notes following the fall showed no documentation that the representative was notified. In interviews, the Subacute Coordinator and the DON both stated that notification to a resident’s representative should occur at the time of a change of condition and that the nurse should document the date and time of notification on the SBAR and in concurrent progress notes. Both verified that the SBAR, Risk Meeting Notes, and progress notes for this incident did not show that the resident’s representative was notified of the unwitnessed fall.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.