Failure to Notify Physician/Family After Fall and to Provide Ordered Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the responsible party after a resident sustained a fall with a resulting laceration, and failure to carry out and report refusals of ordered restorative treatments. The resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and an MDS dated 2/19/2026 documented moderately impaired cognition and a need for supervision or partial/moderate assistance with multiple ADLs, including toileting hygiene, bathing, dressing, eating, oral hygiene, and personal hygiene. On 2/18/2026, progress notes documented that the resident was found on the floor with a forehead cut measuring 2.0 x 0.1 cm, 911 was called, EMS determined there were no significant injuries requiring hospital transport, and the wound was cleansed and monitored. However, in the change in condition fall note for that date and time, there was no documentation that the physician or family were notified of the fall and injury. On 2/23/2026, a telephone/verbal physician order was obtained for a Restorative Nurse Assistant to perform active ROM to both upper extremities and ambulation with a front wheel walker three times weekly for three months. Review of the restorative treatment record from 2/23/2026 through 2/26/2026 showed blanks, indicating that no restorative treatments were provided during that four-day period. During interviews, the resident reported wanting to get out of bed but feeling that his legs were heavier and that he felt tired, and the RN supervisor stated the resident was being monitored for fluid retention. The RNA reported that she had not performed the ROM and ambulation treatments because the resident had not been feeling well on those days, and there was no documentation that the physician was notified of the resident’s refusals of the ordered restorative exercises.
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