F0580

D

Failure to Notify Family/Responsible Party of Fall and X‑ray Results

Buffalo, Missouri Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely notification of a resident’s family or responsible party of a change in condition following a fall and subsequent diagnostic findings. Facility policy revised in January 2025 required that physicians, residents, and families be notified in a timely manner of clinical and environmental changes, including accidents or injuries, and that such notifications be documented. Resident #1, admitted with diagnoses including a left femur neck fracture, experienced a fall when attempting to transfer independently from a wheelchair to bed. A CNA heard a crash, found the resident sitting on the floor, and staff assessed the resident with no injuries initially noted. A nurse obtained a STAT order from a nurse practitioner for X‑rays of the resident’s right shoulder, humerus, elbow, forearm, and wrist, and the X‑rays were completed as ordered.

X‑ray reports from the same day documented soft tissue swelling and changes along the radial neck suggesting a fracture of indeterminate age, with an impression of an abnormal radial neck region. A later progress note described that after the fall the resident complained of right arm pain, an X‑ray showed a radial neck fracture of indeterminate age, and that the medical director and orthopedic physician were aware and ordered a sling. However, there was no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. During interviews, an LPN, an RN, the DON, and the Administrator each stated that staff are expected to notify the resident and/or responsible party of falls, injuries, and X‑ray results and to document this notification in the progress notes, but they acknowledged that such documentation was not present for this resident.