Chillicothe Post Acute

Review of the documents revealed this was completed. On 07/19/25, the DON/Designee provided comprehensive re-education to all nursing staff regarding critical communication protocols.

Physician Notification Requirements for Fall Incidents: It is essential all nursing staff understand the distinction between routine and urgent physician notification requirements following resident falls.

When a fall results in ANY injury, including bruising, swelling, wounds, or head trauma, immediate telephone notification to the attending physician or on-call provider is required.

Fax notification alone does not meet the standard for incidents involving injuries, as direct verbal communication allows for immediate clinical guidance and potential order modifications.

This requirement ensures timely medical evaluation and intervention when indicated.

Emergency Contact Notification Procedures: Staff must attempt to contact ALL listed emergency contacts when notifying families of significant incidents.

When the primary contact cannot be reached directly, staff must make reasonable attempts to contact secondary contacts within the same timeframe.

This includes calling alternative phone numbers, attempting contact with adult children or other designated contacts.

Review of the documents revealed this was completed.

Enhanced auditing processes were implemented effective 07/19/25, with the DON conducting focused audits on a minimum of five fall incidents and notification procedures weekly for four weeks, then as needed thereafter.

These audits specifically evaluate notification methods, timing, and documentation completeness for all incidents involving potential injuries or condition changes, with any identified issues forwarded to the Quality Assurance committee for immediate follow-up.

Review of these documents revealed this was completed.

This deficiency represents non-compliance investigated under Complaint Number 2572441 and Control Number 2572194.

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