Delayed Family Notification of Resident Fracture
Penalty
Summary
A resident with cerebral palsy and severe cognitive impairment experienced a fall during a mechanical lift transfer, resulting in the resident sliding out of the lift sling and landing on her right side. The incident was witnessed by two CNAs, and the resident was assessed by a nurse and a nurse practitioner, who determined she could be moved and later assisted her to lunch. The resident's family member was notified of the initial incident. Subsequently, x-rays were ordered and completed, revealing a right tibia fracture. The physician was notified, and appropriate medical interventions were initiated, including a splint and an orthopedic referral. Despite the discovery of the fracture, there was no documentation that the resident's Power of Attorney (POA) or family member was notified of the new injury on the day it was identified. The record shows that the POA was not informed of the fracture until the following day, contrary to facility policy requiring timely notification of a resident's representative in the event of an injury or significant change in condition. The delay in notification was confirmed during an interview with the DON, who discovered the lapse during a morning meeting and subsequently ensured the family was informed.