F0684

G

Failure to Notify Providers of Post‑Fall Pain and GI Bleeding Symptoms

Kankakee, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess and notify providers of residents’ changes in condition following falls and gastrointestinal symptoms, resulting in delayed treatment for pain and injury. One resident with a history of mesothelioma, peripheral vascular disease, neoplasm-related pain, osteoarthritis, and a prior periprosthetic right hip fracture sustained a witnessed fall in the day room, striking his head on a table and being sent to the hospital for evaluation of a head injury. The hospital emergency department documentation from that visit reflected only a head injury complaint and a negative head CT, with no other injuries identified. After the resident returned to the facility, there was no documentation of his return, and the EMR showed no provider notification regarding new right thigh or hip pain that began the day after the fall.

In the days following this fall, multiple nursing and therapy notes documented new and ongoing right thigh and right lower extremity pain, as well as a change in gait. Therapy staff observed an antalgic gait and a pain score of five out of ten in the right lower extremity, and nursing documentation recorded repeated complaints of right thigh pain with increasing pain scores. Despite these findings, there was no documentation that the physician or nurse practitioner was notified of the new pain or gait change until several days later, when the resident complained of right hip pain and inability to move his right foot. At that time, the nurse reviewed the prior hospital record, noted that no hip x‑ray had been done, paged the physician, and the resident was sent back to the hospital, where imaging revealed an acute comminuted periprosthetic hip fracture requiring operative fixation.

Another resident with acute kidney failure, ESRD, malignant neoplasm of the colon and rectum, melena, and GI hemorrhage experienced nausea and vomiting at the facility. A CNA reported that during one night the resident vomited three times with dark red emesis containing blood and clots and had a dark bowel movement, and stated that this was reported to the nurse. The nurse on that shift later stated she was not told about vomiting blood or black stools. Subsequent nursing documentation noted nausea and a request for anti‑nausea medication, and the resident later received ondansetron for nausea/vomiting, but the EMR contained no documentation that the provider was notified of vomiting blood or black tarry stools. A later lab draw showed a critically low hemoglobin and hematocrit, and the resident was sent to the hospital, where records described persistent vomiting of blood since transfer to the facility, low hemoglobin, and a plan for admission, GI consult, endoscopic evaluation, and blood transfusions.

A third resident with multiple diagnoses including surgical aftercare following digestive surgery, pneumonia, muscle wasting, muscle weakness, cognitive communication deficit, difficulty in walking, and chronic kidney disease sustained a witnessed fall while being transferred with a walker. The CNA guided the resident to the floor, and the resident was assisted back into a recliner before the RN assessed her. The RN later acknowledged she should have assessed the resident before lifting her from the floor. The resident initially denied pain but had pink marks on the middle of her back and right upper shoulder after reportedly hitting her back on a dresser. The nurse did not consider these marks an injury and did not notify the physician, although she administered acetaminophen and later tramadol for back and hip pain that same evening and on subsequent days. Therapy staff documented back pain rated five out of ten the day after the fall and ongoing pain with movement, and nursing documentation later described increasing low back and right hip pain since the fall, leading to orders for imaging and eventual hospital evaluation. Hospital imaging ultimately showed an acute L2 compression fracture. The EMR contained no documentation that providers were notified of the resident’s increasing back and lower extremity pain after the fall, despite repeated administration of PRN pain medications and therapy reports of pain.

Across these three residents, interviews with nursing, therapy staff, the DON, and medical providers confirmed expectations that new pain, changes in gait, vomiting blood, black tarry stools, and injuries or suspected injuries after falls should be promptly assessed and reported to the provider. The facility’s own Change in Resident’s Condition policy required nursing staff to report significant changes, including persistent vomiting and falls or other injuries, to the physician and responsible family member. The documented failures to assess promptly, to recognize and treat post‑fall injuries as potential injuries, and to notify providers of new or worsening pain and gastrointestinal bleeding symptoms constituted the basis of the cited deficiency.