Failure to Notify Family of Resident Falls and Hospital Transfer
Penalty
Summary
The facility failed to ensure timely notification of a resident's family or responsible party regarding significant events, including falls, new physician orders, and a hospital transfer. Record review showed that a resident with multiple diagnoses, including a recent fracture, repeat falls, and muscle weakness, experienced at least two falls. Documentation did not show that the family or responsible party was notified at the time of either fall, nor when a new physician order for an x-ray was made, or when the resident was transferred to the hospital. Interviews with staff and administration confirmed that the family was not notified as required by facility protocol and policy, even though the resident's son was present in the facility later and was informed in person, but not at the time of the incidents. Staff interviews revealed inconsistent understanding and application of the facility's notification policy. While some staff stated that family should always be notified of falls, regardless of the resident's alertness, others believed notification was not necessary if the resident was alert and oriented. The facility's written policy required notification of the physician, family, and responsible party for significant changes in condition and for hospital transfers, but this was not followed in the case reviewed.