Failure to Report Fall and Notify Provider/Family Resulting in Delayed Hip Fracture Diagnosis
Summary
The deficiency involves the facility’s failure to immediately notify the responsible party and physician after a cognitively intact resident experienced a fall with significant pain, resulting in delayed diagnostics and treatment for a fractured hip. The resident had been admitted with traumatic subdural hemorrhage, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet, and had a history of a fall with fracture prior to admission. On the night in question, the resident activated her call light to request assistance to the bathroom, but no one responded, so she attempted to ambulate independently, lost her balance, and fell. She reported that two female staff later found her, picked her up from the floor, placed her in a wheelchair, assisted her to the bathroom, and then back to bed, without performing an examination. The resident stated her right leg hurt after the fall and rated her pain as 10/10. Nurse #1, who was on duty from the evening through the morning shift, stated she was informed by NA #1 around 5:30 AM that the resident had fallen. Nurse #1 and NA #1 assisted the resident off the floor into a wheelchair, asked what happened, but Nurse #1 did not complete an assessment. Nurse #1 observed the resident wince and say “Oh my leg” when being helped up but believed the resident was not hurt because she appeared to have full range of motion. Nurse #1 had the NA take the resident to the bathroom and then back to bed, and later looked in on the resident, who “looked fine,” and then left the room. Nurse #1 did not notify the physician, NP, or responsible party of the fall or the resident’s pain and did not document the fall in the medical record or report it to the oncoming nurse. The DON later confirmed that Nurse #1 failed to report the fall and that there was no corresponding documentation despite a time notation of 5:45 on the 24-hour report. On the following day shift, NA #2 discovered before breakfast that the resident was in pain, saying “ouch” during care and reporting she had fallen during the night. NA #2 relayed this to the Medication Aide, who had not been informed of any fall. The Medication Aide then observed the resident and noted she appeared different than the previous day, with a look of agony and self-reported pain of 10/10. The Unit Manager, who had just arrived, was informed and went to assess the resident, finding her alert, oriented, emotional, and complaining of right leg pain, with inability to bear weight on the right leg, limited range of motion, and increased pain with movement. Vital sign entries throughout the late morning and afternoon documented persistent elevated pain scores (8/10 and then 5/10 and 10/10) with limited or no listed interventions. The Unit Manager learned that neither the Medication Aide nor Nurse #2 had received any report of a fall from the night shift. After reviewing camera footage showing Nurse #1 and NA #1 entering the resident’s room at 5:45 AM, the Unit Manager confronted Nurse #1, who then admitted the fall had occurred and that she had “messed up” by not reporting it. The physician and responsible party were not notified until later that afternoon, after the Unit Manager’s assessment and subsequent orders for imaging, at which point a right hip fracture was identified and the resident was sent to the hospital for evaluation and treatment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify RP/MD of Change in Condition and Missed Meds A resident with dementia, aphasia, dysphagia, malnutrition, and pressure injuries had documented lethargy, decreased alertness, poor intake, pocketing of food/meds, weight loss, and worsening LFTs, but the RP was not promptly notified of the change in condition and end-of-life planning concerns. Another resident on dialysis had repeated missed scheduled doses of multiple meds, including pain, BP, anticoagulant, COPD, psych, and ESRD-related therapies, when out of the facility, and the chart did not show MD notification of the missed doses.
Delayed Notification of Positive FOBT Result: A resident with an ileostomy, scoliosis, fibromyalgia, and thyroid disease was sent to the hospital after a CIC with abnormal VS and later returned with a pneumonia dx. After a stool sample was ordered for C-diff/FOBT, the FOBT was positive for blood, but the resident was not notified for several weeks. The result was not discussed until a later provider encounter, when GI eval and colonoscopy were recommended, and the resident reported frustration about the delay.
Failure to Notify Physician of Elevated Blood Sugars: A resident with insulin-dependent DM, dementia, and other chronic conditions had multiple BG readings above ordered parameters, but staff did not document notifying the MD or NP as required by the physician orders. An LPN acknowledged she did not call anyone, and the Medical Director stated that call orders should be followed.
A resident with severe cognitive impairment had new orders for an antibiotic for cellulitis and ivermectin lotion for head lice, but the facility did not document notifying the RP or family about either change. The RP stated she was upset and shocked by the resident's condition, while the DON said the facility expected nurses to notify responsible parties of changes in condition and new physician orders and to document all contact attempts.
Failure to Notify Physician of Wound Change: The facility did not notify the MD of a significant change in condition for a resident with a chronic scalp wound when new drainage developed. The wound was observed with black discoloration, drainage, and a foul odor, and skin assessments documented drainage, but nursing notes showed no documentation that the MD was informed. Staff stated the MD should be notified of wound changes such as drainage, size, shape, or color, though notification was handled case by case.
A resident with ESRD and an order for hemodialysis three times weekly missed dialysis treatments after becoming verbally combative and resistant to care. Staff notified the dialysis center and the resident representative, but the NP/MD was not notified that the behaviors were interfering with treatment, and the resident was not referred to contract psych services or grief counseling after his son’s death.
Failure to Notify Physician or Responsible Party of Change in Condition and Missed Medications
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident with multiple serious diagnoses, including Alzheimer’s disease, aphasia, dysphagia, and protein-calorie malnutrition. The resident’s record showed moderate impairment in daily decision making, significant recent weight loss, and unhealed pressure injuries. Progress notes documented lethargy, decreased alertness from baseline, non-verbal status, poor oral intake, pocketing of food and medications, worsening liver function tests, declining albumin, and progressive functional decline after hospitalization for acute clinical deterioration. A provider note stated that the resident’s overall clinical decline, poor nutritional status, and worsening hepatic synthetic dysfunction warranted notification of the responsible party to discuss goals of care, with recommendations for palliative care consultation and hospice transition. A later note documented that the responsible party was notified by voice message. During interview, the NP stated there was nutritional decline and that a voice message had been left for the responsible party to recommend hospice, but the responsible party did not return the call. The attending physician stated that they usually try to talk with the responsible party about a change in condition, but because the resident was doing better they did not speak with the responsible party about end-of-life planning. The facility also failed to notify the physician of medications not administered for another resident who was out of the facility for dialysis or appointments on multiple dates. The resident’s orders included multiple scheduled medications for pain, hypertension, ESRD, constipation, anticoagulation, COPD, schizophrenia, chronic pain, hypotension, pulmonary hypertension, supplementation, and depression. Review of the eMAR for two months showed repeated missed doses of several medications, including acetaminophen, amlodipine, calcium acetate, cetirizine, docusate, Eliquis, ipratropium-albuterol, lactobacillus, lidocaine patch, lurasidone, methocarbamol, metoprolol, midodrine, Revatio, renal capsule, and sertraline. Nursing staff documented that the resident was out at dialysis or out of the facility, but the record did not evidence physician notification of the multiple missed medications. Staff interviews confirmed that the resident left early for dialysis, did not receive morning medications before leaving, and that missed doses were simply documented as the resident being out.
Delayed Notification of Positive FOBT Result
Penalty
Summary
The facility failed to notify the resident in a timely manner of a significant health-related test result. The resident was admitted with diagnoses including ileostomy, scoliosis, fibromyalgia, and thyroid disease. After a change in condition with abnormal vital signs, the resident was sent to the hospital, diagnosed with pneumonia, and later returned to the facility. Following treatment with antibiotics for pneumonia and diarrhea, the provider instructed nursing staff to obtain a stool sample for C-diff testing, and an order was entered for a fecal occult blood test (FOBT) on the stool sample. The laboratory result from the stool sample was positive for blood on 05/06/26, but the provider follow-up note on 06/09/26 did not indicate that the resident had been notified of the result. The resident was not informed until the provider encounter on 06/17/26, when the positive FOBT was discussed and a gastrointestinal evaluation and colonoscopy were recommended. During interview, the resident stated she was not notified for a long time about the result and said she is not always informed of important changes in her care. The DON stated residents should be informed in a timely manner of important changes in their care and confirmed the resident was not informed of the FOBT result until 06/17/26.
Failure to Notify Physician of Elevated Blood Sugars
Penalty
Summary
The facility failed to notify the physician per physician orders when Resident #202 had blood glucose readings outside the ordered parameters. Resident #202 was admitted with diagnoses including insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia, and high blood pressure. The quarterly MDS coded the resident as unable to complete the interview and as having short- and long-term memory difficulties, and the resident was receiving insulin injections over the prior seven days. The physician order dated 7/20/2026 directed staff to call the MD if blood glucose was less than 60 or greater than 250, and another order dated 4/26/2026 included sliding-scale insulin with a call to MD for blood sugar 350-400. The MAR and clinical record documented multiple elevated blood sugars, including 318, 347, 319, 308, 256, 308, 278, and 312, but there was no documentation that the physician or NP was notified of these results. An LPN stated she did not call anyone and acknowledged that she should have called, and the Medical Director stated that if there is an order to call, it should be followed.
Failure to Notify Responsible Party of Significant Changes and New Orders
Penalty
Summary
The facility failed to immediately notify the resident's representative when there was a significant change in Resident #1's physical status and when new treatments were ordered. Resident #1 was admitted with diagnoses including urinary tract infection, vitamin B deficiency, weight loss, and visual hallucinations, and her MDS reflected a BIMS score of 3, indicating severe cognitive impairment. On 5/31/26, a new order was received for cephalexin 500 mg by mouth four times a day for cellulitis, but the nursing progress notes did not document family notification related to the new order or the change in condition. On 6/08/26, a new order was received for ivermectin external lotion 0.5% for head lice, and there was also no documentation of family notification related to that new order or the change in condition. During interview, the resident's responsible party stated she was upset that the facility had not notified her about the resident's lower leg infection and lice treatment and said she was shocked by the resident's condition when she arrived at the facility. She verified that one emergency contact had an incorrect phone number and that another had a correct phone number, and stated neither was notified of the changes in condition. The DON stated the facility had been trying to obtain accurate contact information, was not sure why no notification occurred after the new number was obtained, and expected responsible parties to be notified of any change in condition, including new physician orders and treatments. The facility policy stated the resident's family member or legal guardian should be notified of significant changes in status unless otherwise specified, and that the nurse should document all attempts to contact the physician and family or legal representative.
Failure to Notify Physician of Wound Change
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for resident #3 related to a chronic scalp lesion/wound, including the new onset of drainage. During an observation on 6/30/26 at 2:50 p.m., resident #3 was noted to have a scalp lesion/wound with black discoloration, drainage, and a foul odor. Weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25 documented drainage from the scalp lesion/wound. Review of nursing progress notes dated 11/23/25 through 12/9/25 showed no documentation that the physician was notified of the change in condition related to the drainage from the scalp lesion/wound. During interviews, staff stated the physician should be notified of new skin concerns and changes in a wound, including size, shape, color, or drainage, although one staff member said notification was done on a case-by-case basis and earlier changes were not reported because the physician was aware of the lesion on admission. Another staff member stated he did not recall being notified about concerns with the scalp lesion/wound before being notified of a maggot infestation.
Failure to Notify Provider of Behavioral Change Affecting Dialysis
Penalty
Summary
The facility failed to consult the resident’s primary care provider regarding changes in psychosocial status that affected his care, resulting in missed dialysis treatments for one resident. The resident was admitted with end stage renal disease and was ordered to receive hemodialysis every Monday, Wednesday, and Friday at 6:20 AM. The Quarterly MDS documented verbal behavioral symptoms directed toward others, and staff interviews confirmed the resident had verbal outbursts, cursed, and used derogatory language toward staff. Record review and interviews showed the resident missed dialysis treatments because of his behavior toward staff. An LPN notified the dialysis center and the resident representative when one dialysis treatment was missed, and the DON confirmed the missed treatment was due to the resident’s behavior. The DON also confirmed that the resident missed another dialysis treatment because of behavior and that the make-up dialysis was scheduled for a day when the resident could not go because it was the day of his son’s funeral. Interviews with the NP, MDS nurse, SSD, DON, and Administrator confirmed there was no documentation that the primary care provider was notified that the resident’s behaviors were interfering with dialysis treatments. The resident representative stated she was concerned about missed dialysis appointments and was not aware of any grief counseling offered after the death of the resident’s son. Staff also confirmed the resident had not been referred to the facility’s contract psychiatric services, despite the behavioral changes and missed treatments.
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