F0580

D

Failure to Notify Resident Representative of Multiple Falls and Injuries

Strafford, Missouri Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s representative of multiple falls and related injuries in a timely manner, contrary to its own policy on significant condition changes and notification. The facility’s policy, dated 12/24, required licensed nurses to notify the resident’s family/representative and medical practitioner of changes such as new wounds, bruises, skin tears, head trauma, and mobility changes, and to document each attempt at notification. Despite this, documentation for one resident showed repeated falls and injuries without corresponding evidence that the resident’s representative was informed.

The resident involved was admitted on 09/09/24 with diagnoses including Parkinson’s disease, cognitive communication deficits, and a history of falling. An admission MDS dated 12/04/25 indicated the resident was cognitively intact, able to walk with a walker, and required maximum assistance for toileting. The care plan updated 01/28/26 identified limited physical mobility due to weakness, risk for falls related to disease process and muscle weakness, use of a wheelchair, and unwitnessed falls on 02/11/26, 02/19/26, and 02/21/26. Nursing progress notes and fall risk data collection tools documented unwitnessed falls on 02/11/26, 02/14/26, 02/19/26, and 02/21/26, including a skin tear to the right forearm and a hematoma to the right side of the forehead, but did not include documentation of responsible party notification for any of these events.

Interviews with nursing staff and leadership confirmed that family notification did not occur as required. One LPN stated that for unwitnessed falls, staff start neurological checks and notify the doctor and family, but also indicated that non-injury night-shift falls could be reported on day shift. Another RN reported that the night-shift nurse had not notified the family of a fall and that the RN also did not notify the family; the resident’s family member later discovered bruising to the resident’s head and requested hospital evaluation. Additional LPNs acknowledged monitoring the resident after falls and starting neurological checks but either did not notify the family or deferred notification to the next shift. The DON and Administrator both stated they expected staff to notify the physician and family for all falls and to document both the fall and notifications, which did not occur in this case.