Failure to Timely Notify Emergency Contacts and Physicians of Resident Incidents
Penalty
Summary
The facility failed to immediately notify the emergency contact and physician regarding significant changes in condition and incidents affecting two residents. In one case, a resident with moderate cognitive impairment and a history of falls experienced an unwitnessed fall in the early morning. Documentation showed that the physician and family were not notified until approximately ten hours after the incident, despite the resident being found confused and requiring treatment for an aggravated area on the leg. The nurse's notes included late entries, and the author was not identified, limiting the ability to verify the accuracy of the documentation and the timeliness of notifications. In another instance, a resident with moderate cognitive impairment and multiple medical diagnoses, including heart failure and a history of falls, experienced a significant change in mental status and was transferred to the hospital. The resident's emergency contact, her son, was not notified of the hospital transfer and only learned of it upon visiting the facility. Staff interviews confirmed that the responsible nurse did not notify the emergency contact, and the nurse practitioner did not make the notification either, as it was not her responsibility. These failures to promptly notify emergency contacts and physicians of changes in condition, falls, and hospital transfers were identified during the survey. The lack of timely communication was confirmed through record reviews, incident reports, and staff and family interviews, demonstrating a deficiency in the facility's adherence to notification requirements.