Failure to Document and Communicate Fall Led to Delayed Identification of Fractures and Ongoing Pain
Summary
The deficiency involves the facility’s failure to implement effective systems for communication, collaboration, assessment, and documentation following a resident fall, resulting in delayed recognition and response to injury and ongoing pain. Resident #33, who had hypertension, non‑Alzheimer’s dementia, adult failure to thrive, generalized muscle weakness, gait and mobility abnormalities, a history of falls, and used a wheelchair, was care planned as being at moderate risk for falls with interventions such as a wing‑tip mattress and prompt response to assistance needs. On the afternoon of 1/28/26, the Scheduler observed the resident already on the floor, sitting on her buttocks in front of her wheelchair, and summoned a nurse and a medication aide. Nurse #7 assessed the resident, checked range of motion, obtained vital signs, and asked about pain; the resident denied pain, and no apparent injury was noted. The resident was assisted back into her wheelchair and taken to the nurse’s station for brief observation before returning to routine activities. Despite this event, Nurse #7 did not document the occurrence as a fall in the electronic medical record, instead entering it as an “injury” incident type, which did not trigger the facility’s fall‑related User‑Defined Assessments (Fall Risk and Post Fall Evaluations). There was no contemporaneous Post Fall Evaluation or Fall Risk Evaluation completed for the 1/28/26 event, and the fall was not included in the shift report. As a result, management, the primary provider, and the resident’s representative were not promptly informed of the fall. The DON later confirmed that the misclassification of the event in the EMR prevented automatic initiation of the fall assessments and associated management investigation. The NP stated she was never officially notified of the 1/28/26 fall at the time it occurred and that she typically expected a call from the facility when a resident fell. Following the 1/28/26 incident, the resident began complaining of right knee pain on 1/30/26, with documented pain scores and administration of acetaminophen and later tramadol and hydrocodone‑acetaminophen. Nursing staff notified the NP of knee pain and slight swelling, and a right knee x‑ray was ordered on 1/30/26; due to weather and scheduling issues with the outside imaging company, this x‑ray was delayed, and the NP was not made aware of the delay until a later facility visit. The 1/30/26 knee x‑ray, when eventually completed, showed no acute fracture. On 2/4/26, during an on‑site visit, the NP observed the resident to be uncomfortable, irritable, frequently repositioning, and apparently not bearing weight on the right side, with complaints of pain and limited ROM of the right leg; staff at that time reported “no known injury.” Based on this assessment, the NP ordered a right hip/pelvis x‑ray, which showed arthritic changes and osteopenia but recommended CT if clinical suspicion for fracture persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis. Throughout this period, the resident had repeated documented pain scores, and the NP and Medical Director both reported that they and the family only became aware of the 1/28/26 fall after the CT results and subsequent internal investigation, underscoring that the initial fall event and subsequent pain complaints were not effectively communicated or linked by staff to a potential injury from the fall. A late entry Post Fall Note was created by the ADON on 2/12/26, backdated to 1/28/26, describing the resident on the floor in front of her wheelchair, the assessment with no apparent injury, and the use of the PAINAD scale, but this documentation occurred only after the CT scan identified fractures and after the facility began investigating the cause of the injuries. Interviews with the DON, Unit Manager, NP, Medical Director, and other staff confirmed that the fall was initially treated as a non‑injurious event, that required fall assessments and notifications were not completed at the time, and that there were gaps in communication about both the fall and the delays in obtaining imaging. The surveyors concluded that the facility failed to implement effective systems to ensure timely communication and collaboration regarding the resident’s care, including accurate classification and documentation of the fall, prompt notification of the provider and resident representative, and timely follow‑up on persistent pain and imaging orders. Hospital records later documented that the resident was admitted after a fall at the nursing facility with a serious right hip socket fracture and severe pain and difficulty moving. The Medical Director’s first post‑fall visit with the resident occurred on 2/11/26, well after the 1/28/26 fall, and she reported that at that time the resident did not appear to be in pain but was agitated. The NP stated that had she known about the fall when it occurred, she might have ordered different or more extensive imaging earlier and would have considered sending the resident to the emergency department if injury was suspected. The deficiency centers on the facility’s failure to recognize, document, and communicate the 1/28/26 fall as such, failure to complete required fall‑related assessments, and failure to effectively coordinate provider notification and diagnostic follow‑up in the context of the resident’s ongoing pain and functional changes. Overall, the events show that the resident’s fall was not properly reported or documented in real time, the EMR entry did not trigger the facility’s fall management protocols, and key clinical staff and the resident’s representative were not promptly informed of the fall. Subsequent pain complaints, behavioral changes, and functional limitations were managed without clear linkage to a known fall event, and imaging orders were delayed or not effectively followed up, contributing to a prolonged period before the resident’s fractures were identified. These actions and inactions, as documented by staff interviews, record reviews, and practitioner statements, constitute the basis of the cited deficiency for failure to provide treatment and care in accordance with orders, resident preferences, and goals through effective communication and collaboration.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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