The September 22 fall at Manor Court of Freeport went unreported to the resident's healthcare power of attorney despite the nurse documenting plans to make the call at 6 AM. The daughter learned about her mother's fall that afternoon from her aunt, who had visited the resident and heard about the incident directly.
"I was furious because I had not been notified," the daughter told inspectors on October 9. "It is my expectation to be notified of any changes immediately after regardless of the time. I need to know what's going on with my mom."
The resident's progress note from 2 AM showed she fell out of bed but sustained no injuries after assessment by the nurse. The registered nurse wrote she would "call POA/Emergency contact around 6:00 AM" but never made the call.
When confronted by inspectors, the nurse admitted her failure. "She did document she would call at 6:00 AM and she forgot to call," according to the inspection report. The nurse claimed she believed the power of attorney "was notified later that day by the nurse on duty," but provided no evidence of such notification.
The daughter discovered the fall only because her aunt visited the resident on September 22 and the resident mentioned the incident during their conversation. The aunt then called her niece after the visit to relay what she had learned.
Manor Court's Director of Nursing acknowledged the violation during the inspection. "Family should be notified immediately for any changes in condition including falls," she told inspectors. "Notification is important so family members can make informed decision regarding the care of the resident."
The director confirmed the nurse "should have called immediately after the fall."
The facility's own Fall Information Acknowledgement policy, adopted in March 2012, explicitly requires staff to "Notify the POA" for residents who fall. The policy also mandates notifying the physician.
Federal regulations require nursing homes to immediately inform residents, their doctors, and family members of situations that affect the resident, including injuries and changes in condition. The requirement exists regardless of the severity of the incident or time of day.
The inspection found Manor Court failed this basic communication standard for one of three residents reviewed for notification compliance. The violation occurred despite clear documentation of the nurse's intention to make the required call and explicit facility policies mandating family notification.
The resident had been living at Manor Court since her admission date listed on facility records. Her face sheet identified her daughter as both her healthcare power of attorney and emergency contact, making the notification requirement straightforward.
The forgotten phone call represents more than administrative oversight. Family members rely on timely notification to make informed decisions about their loved ones' care, monitor their wellbeing, and coordinate with medical providers when incidents occur.
The daughter's frustration reflected the broader impact of the communication failure. Despite suffering no physical injuries from the fall, the resident's family was left unaware of a significant incident that could have indicated underlying health issues, medication effects, or environmental hazards requiring attention.
The nurse's documented plan to wait until 6 AM to make the notification call already fell short of the immediate notification standard required by federal regulations. Her subsequent failure to make even that delayed call compounded the violation.
Manor Court's acknowledgment of the proper notification standards during the inspection highlighted the gap between written policies and actual practice. The Director of Nursing's clear statement about immediate notification requirements suggested staff understood their obligations but failed to execute them.
The incident illustrates how communication breakdowns can undermine family involvement in nursing home care. When facilities fail to notify family members promptly, they prevent loved ones from participating in care decisions and monitoring their relatives' wellbeing effectively.
The resident's casual mention of her fall to her visiting sister ultimately exposed the notification failure. Without that family visit and conversation, the power of attorney might never have learned about the incident, leaving her unable to assess whether additional safety measures or medical evaluation were needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Court of Freeport from 2025-10-10 including all violations, facility responses, and corrective action plans.