Failure to Timely Notify Physician After Resident Fall With Injury
Penalty
Summary
The facility failed to notify the physician or provider in a timely manner following a resident's fall with injury. A cognitively intact resident with a history of traumatic subdural hemorrhage experienced an unwitnessed fall in the bathroom, resulting in a skin tear to the left elbow, swelling to the back of the head, and complaints of headache. Documentation showed that the incident occurred in the early morning, but the physician or provider was not notified until two days later. The Nursing/Physician Communication form and progress notes did not indicate any earlier notification, and the swelling to the back of the head was not included in the initial communication form. Interviews with facility staff confirmed that the physician should have been notified at the time of the fall, and that documentation of such notification was lacking. The Nursing Home Administrator and Clinical Care Coordinator both acknowledged that if the notification was not documented, it likely did not occur. The resident was subsequently admitted to the hospital with an elevated white count and a small intracranial bleed, but there was no evidence that the physician was informed of the fall and injuries in a timely manner.