Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to inform a resident's emergency contact of a fall in a timely manner, resulting in a delay in notification. The resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom. The fall resulted in a skin tear on the right elbow and pain in the right knee. The incident was documented by an LPN, who assessed the resident and notified the Director of Nursing and the on-call provider but did not contact the emergency contact due to the early morning hour. The LPN passed the responsibility of notifying the emergency contact to the next shift, but the RN on the following shift did not make the call, believing all necessary notifications had been made. The resident expressed a preference for family notification in such events, and the facility's policy required immediate notification of significant changes in health status. The Nursing Home Administrator confirmed that emergency contacts should be notified immediately, regardless of the time of day.
Plan Of Correction
Resident #101 continues to reside in the facility. The resident's care plan has been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated the licensed nurses of the Notification of change policy. Any licensed nurse who has not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will audit fall documentation to ensure that all appropriate parties have been notified in a timely manner. The Director of Nursing/designee will conduct the audit once a week for four weeks, then once every month for three months, to ensure appropriate parties are being notified timely. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025