Failure to Notify Resident's Representative After Hospital Transfer Due to Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative after the resident experienced a fall that resulted in a head injury and required transport to the hospital. The resident, who had intellectual disabilities, reduced mobility, and was cognitively intact, fell in the bathroom, sustained a swollen area above the left eye, and was subsequently sent to the emergency room for evaluation. The facility's policy required notification of family or representatives in the event of significant injury or transfer to another healthcare setting. Despite this policy, the resident's family was not informed by the facility about the fall or the hospital transfer. Instead, the family was contacted by hospital emergency room staff to pick up the resident after evaluation. Interviews with facility staff revealed confusion regarding the location of emergency contact information in the new EHR system, with multiple staff members assuming others had notified the family. The DON confirmed that staff were looking in the wrong area of the EHR and acknowledged that the family should have been notified according to policy.