Failure to Timely Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the physician and responsible party in a timely manner following a resident's change in condition. A resident with a history of sepsis, paraplegia, cancer, and anxiety disorder, who was cognitively intact but dependent on staff for most activities of daily living, experienced a fall during staff assistance. The incident occurred when the resident's knees gave out during a transfer to the toilet, resulting in a small abrasion to the left knee and complaints of worsening back pain with movement. The fall was reported to the nurse by a CNA at 8:00 A.M. Despite the facility's policy requiring immediate notification of the physician and responsible party after such incidents, the physician was not notified until 12:52 P.M., and there was no documented time for when the responsible party was informed. The resident was later transferred to the emergency room, with documentation indicating that both the physician and the resident's son were notified, but again, without specific times recorded. The Director of Nursing confirmed that notifications were not made in a timely manner, and policy review supported the requirement for immediate notification and documentation.