Failure to Notify Physician and Family After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident experienced an unwitnessed fall during the night shift and the facility failed to notify the resident's physician and family member as required by facility policy. The resident, who had a history of a displaced comminuted fracture of the humerus, difficulty walking, anxiety disorder, chronic kidney disease, hypertension, COPD, and hyperlipidemia, was found kneeling on the bathroom floor by a CNA after being alerted by the resident's roommate. The CNA assisted the resident back to bed and reported the incident to the nurse on duty, stating that the resident claimed to have slipped on water and was not in pain. The nurse on duty assessed the resident, found no apparent distress or pain, and did not consider the incident a fall because she had not witnessed it. As a result, she did not complete an incident report, document the event or her assessment in the medical record, or notify the physician or family member. This was in direct violation of the facility's policies, which require notification and documentation whenever a resident is found on the floor, regardless of whether the fall was witnessed or if the resident reports pain. The lack of documentation and notification was later discovered when another nurse completed an incident report after the resident reported the fall and subsequent pain. The resident was later sent to the hospital and diagnosed with a T11 compression fracture. Interviews with staff and review of records confirmed that the required notifications and documentation were not completed at the time of the incident.