Failure to Immediately Notify Provider After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's primary care provider following a change in condition after a fall. The resident, who had a history of cerebral infarction and falls, was found on the floor with lacerations to the right forehead and shoulder. The nurse on duty assessed the resident, applied steri-strips, and documented that the physician was notified. However, subsequent investigation revealed that the nurse did not actually speak to the physician, but instead left a voicemail with the on-call service, which was not received. The nurse also delayed notifying the resident's daughter until several hours after the incident. Facility policy required the nurse to contact the resident's practitioner to inform them of the incident, report injuries, and obtain further orders as needed. Interviews with facility leadership and review of documentation confirmed that the physician was not properly notified, and the on-call service had no record of a message. The nurse's account of the events was inconsistent, and the lack of immediate provider notification resulted in the resident being sent to the hospital only after the family was informed and expressed concern.