Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the resident representative following an accident involving a resident who had a history of repeated falls and multiple medical diagnoses, including urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, and difficulty walking. The resident experienced a fall in the early morning hours, as documented in the Change in Condition Evaluation, but the section for resident or representative notification was left blank. Review of progress notes also showed no documentation that the family was informed of the fall at the time it occurred. Subsequently, the resident was sent to the emergency room for treatment after expressing increased pain and being found to have a left hip fracture. The family was only notified about the fall and the transfer to the hospital several hours after the incident. During interviews, facility leadership confirmed that there was no documentation of family notification immediately following the fall, and acknowledged that the family should have been informed at that time.