Failure to Immediately Notify Resident Representative After Fall and Injury
Penalty
Summary
A deficiency was identified when the facility failed to immediately notify a resident's representative about a change in condition following a fall. The resident, who had a history of cerebral infarction and falls, was found lying on the floor with a laceration to the right forehead and right shoulder. The nurse assessed the resident, applied steri strips, and notified the on-call physician, but documented that the resident's daughter would be notified in the morning rather than immediately. The resident was later sent to the hospital for a head injury. Interviews with facility leadership confirmed that the nurse delayed notification to the resident's daughter, stating she did not believe the situation was critical enough to warrant waking the family member. Facility policy required immediate notification of the resident's family or representative in the event of an incident or accident, as well as when the resident is to be transported to the hospital. The delay in notification was not in accordance with this policy.