Failure to Notify Resident Representative and Physician After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including dementia, Alzheimer's disease, chronic obstructive pulmonary disease, malignant neoplasm of the bronchus or lung, and a history of repeated falls, was admitted to the facility on hospice services. The resident's baseline care plan identified them as being at risk for elopement, wandering, and falls, with interventions in place such as keeping commonly used articles within reach, maintaining clear pathways, monitoring for side effects of psychotropic medications, and assigning a room close to the nurses' station. On a specified date, the resident experienced an unwitnessed fall, as documented in the facility's investigation. Despite the fall, there was no documentation in the resident's medical record indicating that the fall occurred, nor was there evidence that the resident's representative or physician was notified at the time of the incident. Notification to the responsible party and physician did not occur until several days later, after the resident was hospitalized. The facility's fall policy required prompt notification of the physician and resident representative following a fall, but this protocol was not followed in this instance.