Failure to Immediately Notify Physician and Representative After Resident Injury
Penalty
Summary
A deficiency occurred when a nurse failed to immediately notify a resident's physician and representative after the resident was found injured and confused on the floor by her bedside. The nurse, LVN A, did not report the incident to the physician or the resident's representative at the time of the event, despite documenting that she intended to do so. The resident was later hospitalized and diagnosed with acute congestive heart failure with fluid overload and multiple right rib fractures. The incident was not recognized as a fall by LVN A, and she did not consider the need for immediate notification, even though the resident had visible injuries and a change in mental status. The resident involved had a complex medical history, including end-stage renal disease, hypertension, and metastatic pancreatic cancer. She had previously been assessed as cognitively intact, with minimal hearing and vision difficulties, and was independent in activities of daily living. Prior to the incident, the resident had experienced increased confusion, which had been reported to the physician and family. On the day of the event, the resident was found kneeling on the floor with abrasions to both knees, and was assisted back to bed by CNAs before being assessed by LVN A. Interviews and record reviews revealed that LVN A did not notify the physician or the resident's representative immediately after the incident, as required by facility policy. The resident's representative only learned of the fall and injuries upon arriving at the facility later that morning. The medical director confirmed that the expectation was for nursing staff to report unwitnessed falls with injuries to a physician within a reasonable time, such as within an hour. The deficiency was identified as past noncompliance, with the immediate jeopardy period beginning on the date of the incident and ending several days later.