Failure to Immediately Notify Physician and Family After Resident Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and responsible party after a significant change in condition related to an unwitnessed fall. The resident, who had diagnoses including muscle weakness and dementia, was found on the bathroom floor on the evening of January 23, 2026, sitting up and holding onto the toilet, with skin intact, no complaints of pain, vital signs within normal limits, and alert and oriented at baseline. A late-entry progress note documented this event as a change in condition, with the resident stating she slipped and did not hit her head. However, there was no documented evidence that the responsible party was notified immediately after the incident, and the physician was not notified until two days later, on January 25, 2026. A family member later observed that the resident had a black eye and reported not having received any call from the facility about an incident. Staff interviews further clarified the inactions that led to the deficiency. The LVN assigned to the resident on the day the responsible party called stated he did not observe a black eye and was unaware of any change in condition from the previous shift. The CNA who worked the evening when the resident was found on the bathroom floor stated she did not know the incident needed to be documented under a New Alert so it would be visible to other staff. Another LVN acknowledged she forgot to report the incident to the RN, the physician, the family, and did not initiate a Change of Condition (COC), despite stating that reporting and initiating a COC was the expected practice. The DON confirmed that the fall was a change in condition and that staff were expected to assess, monitor, initiate and update the care plan, and immediately notify the physician and responsible party, consistent with the facility’s policy on change in condition notification.
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