The resident's power of attorney and daughter was not contacted until noon, despite facility policy requiring immediate notification of emergency incidents. Staff C, who was responsible for the notification, claimed she could not find the phone number on the paperwork she had.
The fall resulted in serious injuries. The resident sustained a 2mm subdural hematoma and fractures from C7 to T6 vertebrae. The resident was transferred to the emergency department for treatment.
When the daughter finally received the call, she was upset that no one had contacted her earlier about the fall and hospital transfer. The Director of Nursing acknowledged that the family should have been notified much sooner.
Staff C told investigators she looked for the contact information but could not locate it on the printed transfer face sheet. The phone number was listed under "other" and did not populate on the document she was using.
The Director of Nursing was not at the facility when the fall occurred. She arrived at noon, the same time the family was finally contacted. She confirmed that Staff C had not notified the physician about the transfer either.
Federal inspectors found that the facility's own policy, updated in June 2025, clearly states that nursing staff must notify families, power of attorneys and physicians immediately of any changes in condition, falls or incidents. The policy requires staff to document these notifications in the electronic health record.
The Director of Nursing told investigators that her expectation was that family would have been notified much earlier. She said the facility's standard is to notify family or power of attorney immediately when emergency incidents require intervention.
After the incident, the Director of Nursing provided education to Staff C about other places to look for emergency contact information when it doesn't appear on the primary transfer documents.
Staff C acknowledged during the investigation that the resident's daughter was upset about not being called earlier regarding the fall and emergency room transfer. The staff member confirmed she had eventually found the phone number in the admission paperwork after the Director of Nursing arrived and helped locate it.
The facility's notification policy emphasizes that members of the nursing staff must document all family and physician notifications in the electronic health record. This documentation requirement is designed to ensure proper communication occurs and can be verified.
The inspection found that few residents were affected by this violation, but noted it represented minimal harm or potential for actual harm. The failure to promptly notify family members of serious medical emergencies undermines the trust families place in nursing facilities to keep them informed about their loved ones' care.
The two-hour delay meant the resident's family was unaware their loved one had suffered significant injuries and was receiving emergency medical treatment. During those critical hours, the daughter had no knowledge that her parent had fallen from a lift and sustained both brain and spinal injuries requiring immediate hospital intervention.
Federal regulations require nursing homes to notify residents' representatives promptly when there are changes in condition or incidents that affect the resident's health and safety. The facility's own policy reinforced this requirement but was not followed in this case.
The incident highlights the importance of having multiple ways to access emergency contact information and ensuring all staff know how to locate this critical data when standard forms don't display the information clearly. The facility acknowledged that contact numbers listed under "other" categories may not appear on routine transfer documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tabor Manor Care Center from 2025-11-13 including all violations, facility responses, and corrective action plans.