Failure to Notify Physician After Resident’s Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition after a resident alleged rough handling by staff. On the night of February 25, 2026, the resident told a family member that a CNA slammed her left arm onto the bed while attempting to wake her for a brief change. The family member reported that the resident subsequently stated she did not feel safe and wanted to leave the facility. The resident’s admission record showed she was admitted on September 17, 2025, with contractures of the left elbow, wrist, and hand, and her history and physical dated September 18, 2025, documented that she had the capacity to understand and make decisions. The RN supervisor reported that on the morning of February 25, 2026, she became aware of the incident when the resident reported that the CNA was rough with her during perineal care. The RN supervisor stated this alleged incident was considered a change of condition and that the physician should have been notified. The DON stated that staff are expected to notify the physician of significant changes in condition, including allegations of abuse, and that the licensed nurse should have reported the change in condition to the resident’s physician. A review of the medical record showed no documentation that the physician was notified following the allegation of abuse, despite the facility’s “Notification of Changes” policy requiring consultation with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
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