Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative after the resident experienced a fall. The resident, an elderly male with diagnoses including atherosclerotic heart disease, atrial flutter, hypertension, and dementia, was admitted for respite care and was receiving Hospice services. According to the comprehensive care plan, the resident had a fall resulting in a bruise on his forehead. Documentation by the LVN indicated that the resident was found on the floor, assessed, and assisted back to bed, with vital signs and neuro checks within normal limits. However, there was no documentation or evidence that the physician, family, or Hospice were notified of the incident at the time it occurred. Interviews with facility staff, including the DON, ADON, and the LVN involved, confirmed that required notifications were not made following the fall. The LVN admitted to forgetting to notify the necessary parties, despite having received prior training on falls and reporting requirements. The facility's policy on falls prevention and management also required immediate notification of the attending physician and family or guardian in the event of condition changes, which was not followed in this instance.