Failure to Notify Resident Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall with injury and was subsequently sent to a local hospital. The resident, who had diagnoses including unspecified dementia, malignant neoplasm of the head, face, and neck, and hypertension, was assessed as confused with severe cognitive impairment affecting all areas of judgment. The clinical admission assessment also noted wandering behaviors and incontinence. On the day in question, the resident had two falls: the first occurred while family was present in the building, and the second happened later that night after the resident was put to bed. After the second fall, the resident complained of left hip and knee pain and was sent to the emergency room. The LPN involved stated she believed she had notified the family but could not recall specific details and admitted uncertainty about whether the notification occurred. Interviews with the resident's daughters, who are also the resident's powers of attorney, revealed that they were not informed by the facility about the second fall or the transfer to the hospital. They only learned of the hospital transfer when contacted by the emergency room doctor regarding surgery for a fractured hip. Review of the resident's progress notes and incident reports confirmed that there was no documentation of family notification regarding the fall or hospital transfer. The facility's policy requires prompt notification of the resident's representative in the event of accidents resulting in injury or transfer, but this was not followed in this instance.