Failure to Timely Notify Physician After Resident Fall with Injury
Penalty
Summary
The facility failed to promptly notify the attending physician of an unwitnessed fall with facial injury involving a resident diagnosed with dementia, anxiety, heart failure, and atrial fibrillation, who was also on anticoagulant therapy (Eliquis). According to the facility's policy, the physician should be notified within 24 hours of any significant change in a resident's condition, including accidents or incidents. On the morning of the incident, the resident was found on the floor with a swollen right eye and hematoma after attempting to self-toilet. The incident report indicated that the nurse practitioner and family were notified via voicemail, but there was no documented evidence of timely physician notification. Further review revealed that the nurse practitioner was not made aware of the fall until the following day, after observing the resident's facial bruise during a visit. The nurse practitioner confirmed not being notified on the day of the fall and stated that, if notified, would have considered holding the resident's anticoagulant medication. The nurse responsible for the incident report claimed to have notified the nurse practitioner via text message but could not provide proof of this communication. This lapse resulted in a failure to meet the facility's policy and regulatory requirements for timely physician notification following a significant change in a resident's condition.