Failure to Notify Family, Physician, and Hospice After Resident Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s family, physician, and hospice following a fall and change in condition. The resident had multiple serious diagnoses, including carcinoma of the left bronchus, senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, stage IV chronic kidney disease, muscle disorder, unsteadiness on feet, and lack of coordination, and was admitted to hospice with a prognosis of six months or less. The resident’s MDS showed a Brief Interview for Mental Status score of 5/15, indicating severe cognitive impairment. A fall incident report documented that the resident fell at 7:30 p.m. on 12/06/25, with the assigned LPN identified, and specifically noted “No notifications found.” The facility’s Fall Reduction Policy required evaluation for injury and notification of the physician, responsible party, and on-call nurse after a change in condition, and the hospice contract required facility staff to contact hospice’s Administrator on Call for services related to the terminal illness. Interviews and record review confirmed that no notifications were made the night of the fall. Family members and the resident’s Power of Attorney reported they were not notified of the 12/06/25 fall until the following day, 12/07/25. An LPN coming on duty the next morning stated she learned of the fall during shift report and found no documentation that the physician, hospice, or family had been notified; she then attempted to reach family and hospice. At that time, the resident was described as lethargic, unable to speak, and moaning. The hospice RN confirmed hospice was not notified until the morning after the fall and stated that, based on her experience, the resident had a concussion and likely a brain bleed and was comatose post-fall with changes in swallowing and breathing and no emotional response. The DON stated that the resident’s family, provider, and hospice should have been called immediately, and the LPN who was on duty at the time of the fall acknowledged it had been a hectic night and she had not notified the family, physician, or hospice.
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