Failure to Notify DPOA of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's durable power of attorney (DPOA) or emergency contact after the resident experienced a fall and was transferred to the hospital. The resident, who had a history of muscle weakness and hemiplegia following a cerebral infarction, was found on the floor next to her bed with a large bruise on her right knee and a bump and bruise on the left side of her forehead. The LPN on duty initiated neurological assessments, contacted the on-call provider, and arranged for the resident to be transported to the hospital due to concerns about a possible head injury. However, there was no documentation that the resident's DPOA was notified of the incident or the hospital transfer. Interviews with the family member, LPN, DON, and regional nurse consultant confirmed that the DPOA was not contacted regarding the fall and subsequent hospital transfer. The facility's own policy requires notification of the resident's designated representative in the event of an accident or incident resulting in injury and requiring physician intervention or transfer. Review of the incident report and progress notes did not show evidence of such notification, and the family member only learned of the incident after being contacted by the hospital.