Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition policy after a fall experienced by Resident 1. Resident 1 had multiple diagnoses including abnormalities of gait and mobility, unspecified dementia, and a history of falling, and had been assessed as a fall risk on a Fall Risk Evaluation that directed staff to alert the physician if a fall occurred. An MDS assessment indicated Resident 1 had moderately impaired cognition and was dependent for ADLs, requiring supervision or touching assistance. Despite these identified risks, when Resident 1 fell, the required assessments and notifications were not completed. On 1/9/2026 at approximately 3 AM, LVN 2 heard an alarm from the back hallway, entered Resident 1’s room, and found Resident 1 sitting on the floor in front of the roommate’s bed. Resident 1 stated, “I do not know, I just fell.” LVN 2 noted an abrasion on Resident 1’s mid-back on the right side and notified Resident 1’s primary nurse, LVN 3, who stated LVN 2 would resume follow-up. There was no documented evidence that a post-fall assessment was completed, that the physician was notified, or that a Change of Condition (COC) form was initiated for this event, despite the facility’s policy requiring prompt handling, documentation, and physician notification for changes such as bruises, lacerations, and other injuries. During subsequent interviews and record reviews, the DON confirmed that the progress note from 1/9/2026 indicated a fall and that LVN 2, as charge nurse, was responsible for completing the COC, which was not found in the record. The DON also confirmed there was no documentation that the physician was notified or that an assessment was completed after the fall. LVN 1 and LVN 3 both acknowledged that a fall constitutes a change of condition and that it is important to assess the resident and notify the physician and family, yet LVN 3 stated they did not assess Resident 1 after the fall and relied on LVN 2 to “take care of the incident.” The facility’s Change of Condition policy required proper assessment, prompt handling, licensed nurse documentation, completion of a COC, and prompt physician notification with daily assessments, which were not carried out in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.