Failure to Notify POA of Resident Fall and Change in Condition
Penalty
Summary
The facility failed to notify the designated Power of Attorney (POA) of a resident's fall and subsequent change in condition, despite the resident having severe cognitive impairment and being unable to make her own decisions. The resident, who had diagnoses including a displaced intertrochanteric fracture of the right femur, altered mental status, Alzheimer's disease, and dementia, experienced a fall that resulted in a transfer to a local hospital. The facility's records showed that the physician was notified, but there was no evidence that the POA was contacted prior to the hospital reaching out. The POA reported not receiving any calls or messages from the facility and only learned of the incident from the hospital emergency room. Staff interviews revealed inconsistent practices regarding family notification. One LPN stated she attempted to contact the POA twice without success and did not leave a voicemail or attempt to reach other emergency contacts. Other nursing staff and facility leadership confirmed that the policy requires immediate notification of the physician and POA in the event of a change in condition, such as a fall. The facility was unable to provide documentation that the required notification to the POA was made prior to the hospital's contact.