Failure to Notify Responsible Parties and Physicians of Resident Incidents
Penalty
Summary
The facility failed to notify the responsible party and attending physician of changes in condition for two residents. For one resident with a history of falls, muscle weakness, and a previous femur fracture, a fall occurred in his room. The CNA reported the fall to the LPN, but the LPN did not assess or document the incident in a timely manner. There was no documentation of notification to the resident's responsible party or physician regarding the fall on the day it occurred. The resident later complained of pain, and an X-ray revealed a fractured femur, at which point the family and physician were notified. For another resident with severe cognitive impairment, bilateral above-knee amputations, and a history of falls, there were two separate incidents where the resident fell from a Geri chair, resulting in head injuries and transfer to an acute care hospital. In both cases, the nursing notes did not document that the resident's guardian, listed as the responsible party, was notified of the change in condition. Staff interviews confirmed that the guardian was not notified following these incidents. The facility's policy requires prompt notification of the resident, attending physician, and resident representative of any changes in condition, including accidents or incidents resulting in injury. Staff interviews and record reviews confirmed that these notifications did not occur as required in the cases described.