Failure to Notify Responsible Party of Resident Falls Due to Incorrect Contact Information
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident following two separate fall incidents. The resident, who was admitted in April 2025, experienced falls on consecutive days. Nursing progress notes indicated that attempts were made to contact the RP by calling the number listed on the resident's face sheet and leaving voicemails, but there was no response. It was later discovered that the contact number on the face sheet was incorrect, and the RP did not receive the notifications. The correct number was only updated on the day of the resident's discharge, at which point the RP was informed of the falls. Interviews with licensed nursing staff and the Director of Nursing confirmed that the facility was responsible for ensuring the accuracy of contact information for RPs and for promptly notifying them of changes in condition, such as falls. The staff acknowledged that the failure to update and verify the RP's contact information resulted in the RP not being made aware of the resident's falls in a timely manner. Facility policy required immediate notification of the RP and physician in the event of an accident or change in condition, which was not followed due to the incorrect contact information.