Failure to Promptly Notify Resident Representative of Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition, specifically a left radial fracture. The resident had diagnoses including cerebral infarction, Alzheimer’s disease, anxiety, and depressive disorder, and was documented as having severe cognitive impairment and dependence on staff for activities of daily living. On 01/22/26, a STAT x-ray of the resident’s left arm was ordered due to edema, along with an order for ice application. Nursing documentation that morning indicated the nurse practitioner was notified of the edema and that all parties were notified of the new x-ray and ice orders. An x-ray was completed that evening, and the radiology report later that night showed a non-displaced fracture of the distal left radius. On the following day, a nurse’s note documented that the nurse practitioner reviewed the x-ray results with no new orders, but there was no documentation that the resident’s representative was notified of the fracture at that time. Several days later, on 01/27/26, the nurse practitioner evaluated the resident onsite, reviewed the abnormal x-ray results, and new orders were written for a left wrist/hand splint; the nurse’s note again stated that all parties were notified. A hospice progress note that same day showed that hospice staff initially believed the x-ray was negative and only learned of the radial fracture when a staff member entered with a splint and stated the resident had a fracture. The hospice nurse then spoke with facility staff, who confirmed the nondisplaced radial fracture and indicated the resident’s representative would be updated. Documentation shows that the hospice nurse, not facility staff, notified the family of the x-ray results and treatment on 01/29/26. The unit manager LPN confirmed there was no documentation that the family was notified of the fracture when it was identified on 01/22/26, despite facility policy requiring prompt notification of the resident, physician, and resident representative of changes in condition.
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