Failure to Notify Resident Representative After Accident
Penalty
Summary
The facility failed to notify a resident's legal representative following an accident involving the resident. According to the facility's policy, staff are required to immediately notify the resident, consult with the resident's physician, and notify the resident's legal representative or interested family member when an accident occurs that results in injury or has the potential to require physician intervention. In this case, a resident was being assisted from bed to wheelchair by two CNAs when her legs became weak, and she was assisted to the floor. The resident was assessed by an RN, who found no injuries at the time, and there were no immediate complaints from the resident. However, there was no documentation or indication that the resident's representative was notified of the incident at that time. The following day, the resident complained of pain in her right leg, and the physician was notified. Orders were obtained for a radiographic study, which revealed a right tibial plateau fracture. The resident's representative was notified only after these findings, and the resident was subsequently transferred to the hospital. Review of the nursing notes and interviews confirmed that the RN did not notify the resident's representative immediately after the fall, as required by facility policy.