Failure to Notify Legal Representative of Resident Accident
Penalty
Summary
The facility failed to immediately notify a resident's legal representative following an accident involving the resident. According to the facility's policy, staff are required to inform the resident, their medical practitioner, and the resident's representative or guardian of any significant change in condition, including accidents that result in injury or have the potential to require physician intervention. In this case, a resident with a court-appointed guardian and a history of cognitive impairment, dementia, and end-stage renal disease experienced a fall while being transported in a wheelchair to dialysis. The resident panicked in the elevator, jumped from the wheelchair, and complained of knee pain, prompting a physician to order an x-ray. Documentation and interviews revealed that the resident's guardian was not notified of the incident at the time it occurred. The resident's care plan and admission records clearly indicated the presence of a court-appointed guardian, and the facility's computer system had been updated to reflect this information prior to the incident. Despite this, the eInteract Change in Condition Evaluation documented that only the resident was notified, not the guardian. Interviews with facility staff, including the LPN assigned to the resident and the Director of Social Services, confirmed that the guardian's contact information was accurate and available, but staff could not explain why the notification did not occur. The deficiency was identified through review of facility records, interviews with staff and the resident's guardian, and examination of facility policies. The guardian reported learning of the incident only after the resident was sent to the hospital days later for swelling and bruising. The facility's failure to notify the legal representative as required by policy and the resident's care plan constituted a lapse in communication regarding a significant change in the resident's condition.