Failure to Notify Resident's Health Care Agent of Change in Status After Fall
Penalty
Summary
Facility staff failed to promptly notify a resident's Health Care Agent (HCA), who was also a family member and highly involved in the resident's care, of a change in the resident's status following a fall that occurred during occupational therapy. The resident had a history of significant medical issues, including a recent left below-the-knee amputation, peripheral vascular disease, urinary retention with an indwelling catheter, diabetes mellitus, and depression. Documentation showed that the HCA's contact information was available in multiple forms, and the HCA had signed several key documents, indicating her active involvement and legal authority in the resident's care decisions. Despite this, after the fall, the assigned nurse completed the incident report but did not notify the HCA, stating she could not locate the HCA's phone number on the resident's face sheet and only asked the resident if there was anyone to call. The resident later informed the HCA of the fall, not the facility. The Director of Nursing confirmed that it was facility protocol to notify the HCA or responsible party of any fall unless the resident objected, and was unaware that the notification had not occurred. The facility's policy required prompt notification of the resident's representative in the event of a change in condition or status.