Failure to Notify Responsible Party of Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's responsible party of an injury sustained by a resident with severe dementia, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, suffered a hand injury after getting her finger caught in a door. Documentation showed that the CNA reported the incident to the nurse, and the nurse documented that the Power of Attorney (POA) and physician were updated. However, interviews revealed that the resident's private caretaker discovered the injury the following day and was told by staff that they were unaware of the incident. The caretaker later learned from an evening shift CNA about the incident and subsequently informed the resident's daughter/POA, who had not been notified by the facility. Further investigation found that the POA/daughter only learned of the injury through the private caretaker and not from facility staff. When questioned, the Director of Nursing (DON) confirmed that the night nurse did not complete an incident report and admitted to not calling the POA, despite charting that the call was made. The facility's policy requires that incident/accident reports be completed for all injuries and that the physician and legal representative or interested family member be notified within 24 hours. The administrator confirmed that nurses are expected to complete incident reports and notify the POA when a resident sustains an injury, but this protocol was not followed in this case.