Failure to Notify Physician of Significant Injury of Unknown Source
Penalty
Summary
The facility failed to notify the physician of a significant injury for one resident with a history of CVA and abnormal gait who was reviewed for accidents. The resident was admitted on 7/15/25 and experienced a fall on 8/1/25, after which a progress note at 4:00 PM documented transfer to the hospital. When the resident returned from the hospital at 11:40 PM the same day, documentation noted purple bruising to the right fifth toe and right flank, and scattered bruising to the left lower leg, with an additional note at 12:35 AM on 8/2/25 documenting bruising to the right fifth toe. On 8/4/25 at 2:58 PM, a mobile X-ray of the right foot was performed and revealed a fracture at the base of the right fifth toe, and at 3:00 PM a physician’s order for the X-ray was documented. There was no evidence in the clinical record that the physician was consulted or notified between 8/1/25 and 8/3/25 regarding the significant bruising and injury of unknown source to the resident’s right fifth toe. During interviews, a supervisor stated that the expectation for an unwitnessed fall with injuries was that the nurse would call the supervisor, and that the supervisor would notify the doctor and family, complete an incident report, and report to the state agency. The DON confirmed that no call was made to the physician when the injury of unknown source to the right fifth toe occurred, and these findings were reviewed with facility leadership during the exit conference.
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