Failure to Notify Family of Resident Fall Due to Incorrect Contact Information
Penalty
Summary
The facility failed to notify a resident's representative of a fall incident. The resident, who was admitted with osteoporosis, pain, and dementia, was documented as severely cognitively impaired and required partial assistance with bed mobility and transfers. After an unwitnessed fall, the resident was found with a hematoma on the right side of her head. The family member listed as the emergency contact and durable power of attorney was not informed of the fall due to an incorrect contact number being on file. Staff attempted to call the family member, but the voicemail box was not set up, and it was later discovered that the number used was incorrect. The family member only became aware of the resident's fall and resulting injuries upon visiting the facility and observing visible bruising. Interviews with staff confirmed that the contact information was not accurate, and as a result, the family was not notified in a timely manner. The facility's policy requires that medical care problems, including accidents, be communicated to the resident's family or legal representative efficiently and effectively, which did not occur in this instance.