Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's physician and responsible party following an incident in which the resident experienced a fall during staff assistance. According to the facility's policy, the attending physician and the resident's family are to be promptly notified and the time of notification documented. However, review of the incident report revealed that the wrong physician and responsible party were notified after the fall. The resident involved had significant medical conditions, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. Interviews with facility staff confirmed that the LPN on duty did not immediately notify the correct physician or responsible party, mistakenly believing there was a 72-hour window for notification. The Director of Nursing and the Administrator both verified that the correct notifications were not made as required by policy. The deficiency was identified through record review and staff interviews, which showed a failure to follow established procedures for timely and accurate notification after a resident injury.