F0580

J

Failure to Notify Physician and Family After Resident Fall With Significant Injuries

Desoto, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after an accident that resulted in injury and had the potential to require physician intervention. The affected resident was an elderly male with severe cognitive impairment, Spanish-speaking only, with diagnoses including anemia, HTN, DM, CKD stage 2, Alzheimer’s dementia, and non-Alzheimer’s dementia. His admission MDS showed a BIMS score of 00, indicating he was unable to complete the interview, and he required supervision or partial assistance with mobility, transfers, toileting, and ADLs. He had a history of wandering and behaviors such as restlessness, disorganized speech, abusive or resistant behavior, and was care planned as at risk for falls and wandering, with interventions including frequent visual checks and redirection.

On the morning in question, the resident was reported by the primary nurse (LVN-L) to have been roaming in and out of other residents’ rooms and requiring frequent redirection. According to LVN-L’s later interview, at approximately 7:30 AM the resident became angry when redirected, attempted to swing at the nurse, lost his balance, and fell hard against a hallway handrail, striking his face/head and torso. LVN-L stated he observed an abrasion to the right temple/cheek area, helped the resident off the floor, cleaned and bandaged the area, and claimed he completed vitals, skin, fall, and neuro assessments with regular observations, and that the resident was ambulatory, not in pain, and functioning at baseline. However, the resident’s electronic health record for that date contained no clinical documentation of vital signs, fall assessment, post-fall monitoring, neurological assessments, pain assessments, or any change-in-condition assessments related to the fall. There were also no completed post-fall assessments by LVN-L in the record.

Later that day, the resident’s family visited and, at about 5:00 PM, observed a bloody bandage on his face and noted a change in his mental status. During a conference call with LVN-L, the family learned for the first time that the resident had fallen and hit his head on the rail earlier that morning. The family questioned why they had not been notified and expressed concern about increased confusion. LVN-L acknowledged to the family and to the surveyor that he had not notified the responsible party, the physician, the DON, the ADON, or the weekend supervisor about the fall and injury, stating he was not aware he needed to notify the family and that he was busy with 60 residents and ongoing behaviors. He told the family the resident was fine and allowed them to sign the resident out and transport him to the hospital on leave rather than arranging emergency transport. Hospital records later showed the resident had right 6th and 7th rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s medical provider (NP-A) reported he was not notified of the fall details until two days later and stated he expected immediate notification when a resident falls with a head injury. Interviews with the Administrator, DON, ADON, weekend supervisor, other nurses, and CNAs consistently described that facility protocol required immediate assessment, documentation, and notification of the physician, responsible party, and nursing leadership after a fall or change in condition, and that this did not occur in this case.