Failure to Immediately Notify Resident's Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's representative following an accident that resulted in injury and required transfer to an acute care hospital. According to the facility's policy, immediate notification of the patient, physician, and representative is required in the event of an accident resulting in injury and a decision to transfer the patient. Record review showed that the resident, who had a history of stroke, sustained a fall resulting in a laceration above the left eye that required sutures. Documentation indicated that the name of the family or representative notified was listed as unknown shortly after the incident. Further review of records did not provide evidence that the resident's representative was informed immediately of the accident and subsequent hospital transfer. During an interview, the Assistant Director of Nursing Services was unable to provide proof that the required notification occurred. The lack of timely communication with the resident's representative following the incident constituted a deficiency in meeting regulatory requirements.