Failure to Timely Notify Guardian of Resident Fall
Penalty
Summary
The facility failed to promptly notify the guardian of a resident's fall, as required by policy. A resident with a history of right femur fracture, chronic lymphocytic leukemia, and legal blindness, who was dependent for transfers and had moderately impaired cognition, experienced a fall next to the bed. The fall was discovered by a CNA, who notified an LPN, and together they assisted the resident back to bed. No new injuries were observed at the time, and the CNA did not notice anything wrong until the following day, when a leg issue was identified and reported to another LPN. Despite the incident, the guardian was not informed of the fall or the resulting leg injury until the resident was transferred to the hospital two days later. The facility's policy requires immediate notification of the resident's practitioner and family or representative following such incidents, but documentation and interviews confirmed that the guardian, physician, and DON were not notified until well after the event. The late entry in the progress note and interviews with staff and the guardian's office corroborated the delay in communication.