Delayed Physician Notification After Resident Fall
Summary
The facility failed to ensure timely physician notification and response to a resident's complaints of pain following a fall. Resident #116, who had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and essential tremors, fell in the Centrum area on 11/11/24 at 7:50 P.M. The resident was observed by a CNA attempting to walk from her wheelchair and subsequently fell on her right side. Initial assessments by the nursing staff did not reveal any immediate injuries or complaints of pain, and the resident was returned to her wheelchair and later to bed. During the night, the resident began to report pain in the right hip/thigh area. Despite this, the on-call service instructed the staff to contact the physician in the morning rather than immediately. It was not until the morning of 11/12/24 that the physician was contacted, and an X-ray was ordered, revealing an acute subcapital hip fracture. The resident was then sent to the emergency department for further evaluation and treatment. Interviews with the Director of Nursing, the resident's daughter, and nursing staff revealed concerns about the delay in addressing the resident's pain and the lack of immediate physician intervention. The facility staff believed they had followed protocol by contacting the on-call service, but the service's refusal to connect them with the physician resulted in a delay in care. The deficiency was investigated under Complaint Number OH00160374.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure 24-hour physician response, affecting a resident with a knee laceration. Despite attempts to contact the on-call nurse practitioner, no return call was received, leading to the resident being sent to the ER without a physician's order. The resident was later diagnosed with acute metabolic encephalopathy and other conditions. Interviews revealed ongoing issues with after-hours physician responsiveness and inadequate communication protocols.
Failure to Ensure 24-Hour Physician Response
Penalty
Summary
The facility failed to ensure that physician services responded to requests for resident care 24 hours a day, affecting one resident and potentially impacting all 83 residents. Resident #78, who had a complex medical history including Alzheimer's disease, chronic atrial fibrillation, and other conditions, experienced a laceration on her left knee. Despite attempts to contact the on-call nurse practitioner, there was no return call, and the resident was eventually sent to the emergency room without a physician's order. The incident began when staff noticed bleeding from the resident's left leg and informed the nurse, who assessed the wound and attempted to contact the on-call nurse practitioner. The nurse applied steri strips and a dressing without an order due to the lack of response. The resident's condition worsened, leading to her being sent to the hospital, where she was diagnosed with acute metabolic encephalopathy, acute kidney disease, and mild hypernatremia. Interviews with facility staff revealed ongoing issues with the responsiveness of physician services after hours, which had been previously addressed in their Quality Assurance and Performance Improvement program. The facility's communication protocol did not provide direct contact numbers for the physician or medical director, complicating efforts to obtain timely medical intervention. The resident's representative expressed concern over the delay in communication and the extent of the injury when finally informed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
