Failure to Notify Physician After Resident Injury
Penalty
Summary
The facility failed to notify the physician when a resident sustained an injury during a transfer. Specifically, a resident with diagnoses including Alzheimer's disease, unsteadiness on feet, and muscle weakness, suffered a laceration on the lower left leg that required staples. The family was not notified until the resident was sent to the hospital, and there was confusion regarding whether the on-call physician had been contacted at the time of the incident. Documentation by the LPN indicated the on-call physician was notified, but the nurse practitioner later confirmed that the on-call provider was not actually informed, and no notes were received regarding the incident. Interviews revealed that the LPN used her personal cell phone to attempt notification, citing difficulty accessing the facility's designated device for contacting providers. The nurse practitioner was unaware of the incident until informed by the day shift nurse, and questioned why the resident was not sent to the hospital immediately. The facility's policy requires notification of the attending physician for any accident or incident resulting in injury, but this was not followed in this case, as confirmed by the Director of Nursing during the exit conference.