Failure to Report Resident Fall and Notify Physician and Family
Penalty
Summary
The facility failed to report a resident's fall to the licensed nurse, which resulted in the resident's physician and family member not being notified of the incident. A Certified Nursing Assistant (CNA) found the resident on the floor by the bed, but did not immediately report the fall to the nurse on duty, as the nurse was not readily available and the CNA became occupied with other duties. The fall was not documented in the resident's medical record, and the only reference to the incident was found in the risk management section, which was not accessible to survey staff. The resident's family member and legal Power of Attorney was not informed of the fall and only learned about it through a third party. The resident's medical record did not contain documentation of the actual fall event, though it did show a post-fall neurological check and subsequent monitoring. The nurse manager confirmed that the fall was not reported by staff at the time it occurred, and that the incident was only discovered after questioning staff members. Facility policy requires that all accidents and incidents be reported to the department manager and the charge nurse so that appropriate medical attention can be provided, but this protocol was not followed in this case.