Failure to Notify Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident's emergency contact and legal representative following a significant fall incident. The resident, who had a complex medical history including B cell lymphoma, lung cancer, intracerebral hemorrhage, atrial fibrillation, and other serious conditions, experienced a fall in his room, resulting in head, upper body, and left hip trauma with moderate pain. Nursing documentation confirmed that the physician was notified, but there was no documentation that the resident's emergency contacts were informed of the incident. The incident report also validated that no family notification was made regarding the fall. Subsequent nursing notes indicated that the resident's pain worsened, and the resident was eventually sent to the hospital, where an acute left hip fracture was diagnosed and surgically repaired. Interviews with nursing staff and the resident's spouse and daughter confirmed that neither the emergency contact nor the POA were notified of the fall or the change in the resident's condition until the spouse arrived at the facility the following day. The facility's administrator and DON acknowledged that the family was not notified of the incident, which was contrary to the facility's policy on resident rights.