Failure to Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to immediately notify the physician after a resident experienced a fall. The resident, who had multiple diagnoses including cerebral palsy, contractures, kyphosis, convulsions, periprosthetic fracture, atrial fibrillation, osteoarthritis, congestive heart failure, and hearing loss, was dependent on staff for activities of daily living and was identified as being at risk for falls. During morning care, a CNA was providing care alone, rolled the resident onto their side, and the resident's legs slid off the bed, resulting in the resident being lowered to the floor. The CNA notified a nurse, who found the resident on the floor, but the nurse did not notify the physician of the fall and did not complete an incident report. The nurse also failed to communicate the fall to the oncoming nurse during shift change, resulting in further lack of physician notification. The facility's policies required prompt physician notification for any falls or incidents, but there was no documentation in the medical record to support that this occurred. The DON confirmed the expectation that all nurses notify the physician of any falls or incidents, in accordance with facility policy.