F0580

D

Failure to Notify Physician and Representative After Resident Falls With Injury

Overton, Texas Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify a resident’s representative and attending physician of significant changes in condition following falls. An elderly male resident with senile degeneration of the brain, severely impaired cognition, and a history of falls prior to and during his admission was identified as being at risk for falls in his comprehensive care plan dated 6/22/25. A comprehensive MDS indicated he was unable to complete the BIMS interview and had severely impaired cognition. Despite this known fall risk and cognitive impairment, required notifications were not made after two separate fall incidents.

Record review showed that on 6/22/25 at 5:16 a.m., the resident sustained a witnessed fall in which he ran into a door facing and fell to the floor, resulting in a 1x0.5 cm laceration to the bridge of his nose. The incident report for this fall, completed and signed by LVN A, documented that the resident representative was not notified. The corresponding nursing progress note, entered at 5:18 a.m. by LVN A, described the fall and treatment (area cleaned and topical antibiotic applied) but contained no documentation of notification or attempted notification of the responsible party. The resident’s responsible party later reported that she was not called about this fall and only discovered the injury when she visited the facility the next day and saw the laceration on his nose.

A second incident report dated 6/27/25 at 1:51 a.m. documented an unwitnessed fall for the same resident. In the notifications section of this report, also signed by LVN A, it was recorded that the attending physician was not faxed, the physician was not notified, and the resident representative was not notified. The nursing progress note for this fall, entered at 1:52 a.m. by LVN A, likewise contained no documentation of physician or responsible party notification or attempted notification. Interviews with another LVN, the DON, and the administrator confirmed that facility practice and written policy required notification of the physician and resident representative after accidents or incidents involving injury, and that the incident reports would reflect whether such notifications were made. Facility policy and resident rights documents further stated that the nurse must notify the attending physician and the resident’s representative when the resident is involved in an accident or incident resulting in injury or requiring a physician visit.