Failure to Notify Physician After Resident Left Outside Overnight
Penalty
Summary
The facility failed to notify the resident's physician of a significant incident involving a resident who was left outside all night. The resident, who was cognitively intact with a BIMS score of 14 and independent in activities of daily living, reported being unable to re-enter the facility after going outside to smoke due to difficulty opening a heavy door. The incident was discovered when a staff member heard the resident pounding on the courtyard door the following morning. Documentation shows that the resident reported feeling too weak to open the door, and while the nurse notified the physician of the resident's reported weakness, there was no documentation that the physician was informed about the resident being left outside overnight. The facility's policy requires immediate notification of the physician and the resident's representative in the event of an accident or change in condition. During interviews, the facility physician confirmed they were not informed of the incident and expressed that they expected to be notified. The DON also verified that the clinical record lacked documentation of physician notification regarding the incident, despite facility expectations for staff to report such events.