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:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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