Failure to Notify Family of Resident Falls
Penalty
Summary
The facility failed to notify a resident's family member of multiple falls experienced by the resident, despite facility policy requiring notification of the physician and responsible party after such incidents. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 6, and multiple diagnoses including catatonic schizophrenia, anxiety disorder, repeated falls, hypertension, major depressive disorder, and type II diabetes. Progress notes documented several falls over a two-month period, but there was no documentation that the family was informed of these events or any resulting injuries. The resident's family member confirmed that they had not been notified of recent falls and only learned of an injury after observing a cut above the resident's eye during a visit and inquiring with nursing staff. Interviews with facility staff indicated that the expectation was to notify families and physicians after a fall, but this was not consistently done for this resident.