Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Responsible Party (RP) after the resident experienced a fall. Review of the resident's admission record indicated the resident had multiple rib fractures on the left side of the ribcage. Documentation in the SBAR Fall Report of Incident incorrectly listed the resident as her own RP and stated that the RP was notified. However, during interviews, the licensed nurse confirmed that he documented the resident as her own RP and did not notify the actual RP. Further review with the Director of Nursing (DON) confirmed that the clinical record was inaccurate and that the RP should have been notified, especially in case the RP wanted to make decisions such as sending the resident to the emergency room. The facility's policy on Fall Prevention and Response required notification of both the physician and the RP following a fall, but this was not followed in this instance.