Failure to Notify Physician of Resident Head Injury
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition following a head injury sustained during staff-assisted care. The resident, who had severe cognitive impairment, dementia, a recent femur fracture, and was dependent on staff for all activities of daily living, was found with a three-centimeter laceration on his forehead. Staff discovered the injury after finding the resident in bed with a blood-soaked Band-Aid, and the wound was determined to require sutures. There was no documentation of nursing assessment or progress notes at the time of the injury prior to its discovery by the evening nurse. Witness statements from CNAs involved in the resident's care indicated that the injury occurred during or after a Hoyer lift transfer. Both CNAs left the resident unattended in his room, and upon returning, one CNA found the resident partially out of bed and later noticed the head wound after the resident became agitated and struck the CNA. The CNAs reported the injury to each other, but there was uncertainty about whether the incident was reported to a nurse or if the resident was assessed immediately, especially since the unit nurse had left early that day. The facility's policy required immediate notification of the physician for accidents requiring intervention. However, the physician was not notified until the evening nurse discovered the injury hours later, resulting in a delay in medical evaluation and treatment. The lack of timely documentation and communication with the physician constituted a failure to follow established protocols for changes in resident condition.