Failure to Notify MD After Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician at the time of an accident that resulted in a head injury. The resident had paranoid schizophrenia, lack of coordination, and gait and mobility abnormalities, and an MDS dated 1/29/26 documented severe cognitive impairment and a need for supervision with most activities of daily living. On 3/7/26 around 3 AM, a CNA observed the resident turn a corner in the hallway and bump his face into the edge of an open door that protruded into the hallway, resulting in a cut above the right eye with bleeding. The CNA brought the resident to the nurses’ station, where an LVN and an RN assessed the cut and provided first aid. Despite the observed accident and visible injury, the LVN and RN on the night shift did not initiate a Change in Condition Evaluation (CIC) form and did not notify the resident’s physician of the incident. There was no documentation in the resident’s progress notes or CIC records related to the 3 AM accident. As a result, the day shift staff initially considered the injury to be of unknown origin because they were unaware of how the resident sustained the right eye injury. The facility’s later investigation confirmed that the injury occurred when the resident walked into the door during the night shift. Later that morning, at 8:45 AM, a CIC was completed when the resident was seen in the shower room rubbing his right eyebrow, with bleeding noted and a 1.2 cm cut on the right eyebrow and discoloration of the right upper eyelid. The CIC documented that the skin change and a neurological assessment were relevant to the change in condition, and the physician was notified at 9 AM and recommended transfer to a general acute care hospital for medical clearance. The facility’s policy titled “Change in Condition” required licensed nurses to notify the physician and the resident’s representative when there is an incident or accident involving the resident, or an accident resulting in injury with potential need for physician intervention. The failure of the night-shift licensed nurses to initiate a CIC and notify the physician at the time of the accident constituted the cited deficiency.
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