Failure to Notify Physician and Family After Resident Fall with Injury
Penalty
Summary
The facility failed to notify both the physician and the family after a resident experienced a fall with injury. The resident, who had a moderate cognitive deficit and was at risk for falls due to impaired balance and congestive heart failure, was found on the floor in his room after an unwitnessed fall around midnight. He complained of pain in his left leg and was given Tylenol before being transferred to a recliner. Although a fax was sent to the physician, there was no immediate phone contact, and the fax was not acknowledged by the physician until several days later. The family was also not notified at the time of the incident. Staff interviews revealed that the overnight nurse did not call the physician or the family, believing that unless it was an emergency, the morning nurse would handle family notification. The resident continued to experience pain and was unable to bear weight on his leg during subsequent checks. He was eventually sent to the hospital in the morning, where a fractured hip was diagnosed. Facility policy required notification of the physician and family in the event of a significant change in status, but this was not followed in this case.