Failure to Promptly Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following a fall. The resident, a female with a history of repeated falls, decreased mobility, legal blindness, and other significant medical conditions, experienced a fall in the bathroom while attempting to pull up her socks. The incident was discovered by a CNA, and the resident was found on the floor with a minor bump on her head. Vital signs were taken, and the family was notified, but the physician was not promptly informed of the incident as required by facility policy. The charge nurse on duty at the time of the fall did not notify the physician until the following day, after being instructed to do so during a morning meeting. The nurse stated she was unaware of the requirement to contact the physician immediately and was not familiar with the facility's fall policy. Interviews with the DON and ADON confirmed that the facility's protocol mandates prompt physician notification after a fall, and that it was the charge nurse's responsibility to do so. Review of the facility's fall management policy corroborated this requirement.