Failure to Timely Notify Family After Resident Fall
Penalty
Summary
A resident with severely impaired cognitive functioning, as indicated by a BIMS score of 5, experienced a fall in the facility's bathroom. The resident required substantial to maximal assistance with activities of daily living and had a history of safety concerns, including a risk for falls and skin picking. On the evening of the incident, staff found the resident on the bathroom floor, assessed her for injuries, and noted complaints of hip and knee pain, but no visible injuries or swelling were observed. Neurological checks were initiated and found to be within normal limits. Despite the fall and the resident's condition, the nurse on duty did not notify the resident's family on the day of the incident. The family was informed the following day, after the facility became aware that notification had not occurred as required. Facility policy directs staff to document the date and time of family notification following accidents or incidents, but this was not followed in this case.