F0580

D

Failure to Promptly Notify Physician After Fall With Head Injury and Acute Change in Condition

Trenton, Missouri Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow multiple facility policies requiring prompt verbal notification of a resident’s physician after significant changes in condition and accidents. The facility’s Notification of Changes policy required prompt consultation with the resident’s physician and notification of the resident and representative when there was a change requiring notification, including accidents resulting in injury or with potential to require physician intervention. The Incidents and Accidents policy required the nurse to contact the resident’s practitioner after an incident/accident to report injuries or findings and obtain orders, and to document the incident, findings, interventions, and notifications. The Notifying Clinicians policy required clinicians to be notified of changes in condition, emergent situations, and incidents such as falls, out-of-range vital signs, altered mental status, and any change from baseline, with an expectation of verbal communication when an immediate change in the plan of care might be needed.

Resident #2 was cognitively intact, used a wheelchair, and required supervision or assistance for toileting, bathing, and hygiene. The resident was on anticoagulant and antiplatelet medications, with diagnoses including heart failure, diabetes, and hypertension. The resident’s care plan directed staff to follow the facility fall protocol if a fall occurred. On 01/21/26 at approximately 1:45 A.M., RN A heard the resident calling for help and found the resident on the floor with his/her head against the sink cabinet. RN A observed a four-centimeter laceration to the left side of the head with a moderate amount of bleeding, cleaned the wound, and applied two Steri-Strips, and also noted five other abrasions and a kiwi-sized area on the resident. Later documentation that morning described the resident’s skin as jaundiced, cold, and clammy, and fragile. There was no documentation that the physician was notified of the fall, the head laceration, the abrasions, or the skin findings. RN A later stated he/she did not call the physician, but instead sent a text message to the nurse practitioner and Administrator around 5:23 A.M., and believed non-emergent incidents could be reported by text.

On 01/24/26 at about 8:00 P.M., LPN B documented that the resident became unresponsive for about one minute and then had seizure-like activity for about 45 seconds before becoming responsive again. LPN B documented that the DON and ADON were notified and that the resident was monitored and required three staff for transfer, but there was no documentation that the physician or NP was notified of this acute change in condition. LPN B later stated the resident had no prior similar activity, that the resident was responsive to painful stimuli and appeared fine afterward, and that he/she monitored the resident every 30 to 60 minutes; LPN B acknowledged he/she should have notified the physician. The physician/NP was not notified until 01/25/26 at 12:00 P.M., approximately 16 hours after the unresponsiveness and seizure-like activity, when LPN A informed the NP of the episode, the resident’s jaundiced color, and swollen areas to the right hip and abdomen, at which time an order was given to send the resident to the emergency room.

Interviews with facility leadership and providers confirmed that the facility’s expectations were not met. The Administrator stated that when a resident is injured or has a change in condition, staff are to call the resident’s physician. The DON stated nurses should have notified the resident’s provider as quickly as possible and should also notify the ADON, Administrator, guardians, and regional administration, and document physician notification in the medical record. LPN A described that when a resident falls or has an incident, the nurse should assess, obtain vital signs, complete risk management documentation, update the care plan, initiate interventions, and notify the primary care provider and leadership. The NP stated she expected to be notified of injuries, acute occurrences, or urgent issues right away and that, in this resident’s case, she would have expected a call rather than a message. The Medical Director stated the nurse should have called the physician about the fall with injury and that the resident should have been sent to the hospital. The resident’s primary physician stated that he/she or the NP should have been called when the resident fell. These statements, combined with the documentation, show that staff did not promptly notify the physician of the resident’s fall with head injury and subsequent episode of unresponsiveness with seizure-like activity, contrary to facility policy and provider expectations.