Failure to Notify Family/Representatives After Resident Falls
Penalty
Summary
The facility failed to ensure timely notification of family members or resident representatives following a change in condition, specifically after resident falls, for four out of five residents reviewed. In each case, clinical records and interdisciplinary team notes documented the occurrence of falls, but lacked evidence that the family or resident representative was informed. The residents involved had significant cognitive impairments or diagnoses such as Parkinson's disease, dementia, Alzheimer's disease, schizophrenia, seizure disorder, and depression. Falls were documented in the residents' health status notes and reviewed by the interdisciplinary team, but there was no documentation of required notifications to families or representatives. The facility's policy, last revised in 2018, requires that both the physician and family be notified when a resident falls, and that this notification be recorded in the medical record. Despite this policy, the records for the affected residents did not include documentation of such notifications. The Assistant Director of Nursing confirmed that all provided information was part of the clinical record and that any additional internal documents were not included in the clinical record reviewed.