Failure to Notify Responsible Party of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the resident's responsible party following an unwitnessed fall that resulted in injury and required physician intervention, as well as during the subsequent transfer of the resident to the hospital. Specifically, after the resident was found on the floor with complaints of back pain, the nurse on duty attempted to call the responsible party but only left a voicemail and did not make further attempts to reach them or ensure the message was received. Documentation indicated that the responsible party was notified, but interviews revealed that the responsible party did not receive timely information about the fall or the hospital transfer. Further review showed that another nurse failed to notify the responsible party about the resident's transfer to the hospital after abnormal x-ray findings. Instead, communication was made with a family member who was not listed as the responsible party on the resident's face sheet. This led to confusion and a delay in the responsible party being informed about the resident's condition and hospital transfer. The responsible party only learned of the events after being contacted by the other family member and upon visiting the facility in person. The resident involved had multiple complex medical conditions, including atrial fibrillation, diabetes, and a history of falls, and was dependent on staff for most activities of daily living. The facility's own policy required immediate notification of the responsible party in the event of a significant change in condition, such as a fall or hospital transfer. However, staff failed to follow this policy, resulting in a lack of timely communication with the appropriate family member regarding the resident's fall, abnormal x-ray results, and transfer to the hospital.