Failure to Notify Physician After Resident Fall with Major Injury
Penalty
Summary
The facility failed to notify the physician immediately following a fall with major injury for a resident with multiple complex medical conditions, including dementia, cancer, and morbid obesity, who was actively receiving chemotherapy. The resident, identified as a fall risk and dependent on staff for mobility and transfers, was being assisted by three staff members from bed to wheelchair when their legs became weak, resulting in a fall. Despite the care plan and physical therapy directives requiring the use of a mechanical lift for all transfers, the staff did not utilize the lift during this incident. After the fall, the resident was assessed, reported no complaints at the time, and was transferred to a scheduled medical appointment. Facility documentation initially indicated that the physician was notified shortly after the incident; however, an investigation revealed that no such notification occurred. The Director of Nursing Services confirmed that the nurse did not use the required encrypted provider notification system, and the physician only became aware of the incident the following day after being contacted by the Emergency Department, where the resident was diagnosed with a tibia/fibula fracture. The facility's policy required immediate notification of the physician and responsible parties in the event of an accident resulting in injury, which was not followed in this case.