Failure to Document, Notify Physician, and Monitor Change of Condition After Resident Head Injury
Penalty
Summary
The facility failed to document an assessment, notify the attending physician, initiate a Change of Condition (CoC), and monitor the CoC for a resident who reported hitting her head in the bathroom. The resident, who had a history of cerebral infarction and dementia but was assessed as having intact cognition, informed the Director of Staff Development (DSD) that she had hit her head on a grab bar. Despite this report, there was no documentation in the resident's progress notes regarding the incident, assessment, or any subsequent monitoring or treatment. Interviews with the DSD and Director of Nursing (DON) confirmed that the DSD did not notify the resident's physician, document an assessment, or initiate a CoC as required by facility policy. The facility's policy mandates prompt notification of the physician and documentation of any changes in a resident's condition, including accidents or incidents. The DON acknowledged that the required steps were not taken, and the incident was not properly managed or recorded in the resident's medical record.