Failure to Notify Resident's Representative of Injury
Penalty
Summary
The facility failed to immediately notify the resident's representative of an accident involving a resident, which resulted in an injury. The incident involved a resident who was found on the floor with a pool of blood at the head and hands, indicating a fall. The resident sustained a contusion and a laceration on the forehead, which continued to bleed. Vital signs were taken, and emergency services were called, resulting in the resident being transported to the emergency department. Despite the severity of the incident, the resident's representative was not informed immediately, as the notification was delayed until later in the morning. The facility's policy, revised in December 2016, mandates prompt notification of the resident's representative in the event of an accident or incident resulting in injury. However, in this case, the notification was not made until several hours after the incident, contrary to the policy requirements. The Director of Nursing confirmed during an interview that the resident's representative was not notified immediately of the fall and subsequent hospitalization, highlighting a deficiency in adhering to the notification requirements outlined in 42 CFR Part 483 and the 28 PA Code regulations.
Plan Of Correction
1. D.O.N. / A.D.O.N. will provide education to nurses re policy of notification of change of condition and also use of INTERACT Tools for Change of Condition by 9-13-24. 2. D.O.N. / A.D.O.N. will provide education to nurses to enter all vital signs in Vital Signs tab instead of just nursing notes so that alerts for changes in condition are active by 9/13/14. 3. Clinical team will audit all changes in condition during clinical meeting by 9/1/24. 4. D.O.N. will develop a change in condition checklist that includes notifying responsible parties for each change of condition. Checklist to be completed at time of change. 5. D.O.N. will audit weekly for 4 weeks, then biweekly for one month, then monthly, with results reported to QAPI and to Regional Leadership Team.