Failure to Notify Physician of Resident's Post-Fall Behavior
Penalty
Summary
The facility failed to notify the physician regarding a resident's post-fall behavior and refusal of care, which was a deficiency identified during the survey. The resident, who had been admitted with diagnoses including chronic obstructive pulmonary disease and chronic pulmonary edema, experienced a fall and was sent to the hospital for evaluation. Upon returning from the hospital, the resident exhibited confusion, combativeness, and refusal of care, including vital sign checks. Despite these significant changes in behavior, there was no documented evidence that the physician was notified of the resident's condition. Interviews with facility staff, including LPNs and the Supervising Nurse, confirmed that the resident's refusal of care and aggressive behavior were not communicated to the physician, contrary to the facility's policy. The facility's policy required that any change in condition, such as refusal of care, should be assessed, documented, and communicated to the primary care provider. The lack of notification to the physician about the resident's condition post-fall was a critical oversight, as confirmed by the Director of Nursing and other staff members.