Failure to Notify Physician and Responsible Party After Resident Fall With Major Injury
Penalty
Summary
The facility failed to immediately assess and notify the physician and responsible party following a fall with major injury for one resident. The resident was found sitting next to his bed and was unable to articulate what happened. The LPN and CNA assisted the resident back to bed, and the LPN documented that there were no injuries or pain and that a body assessment was conducted. However, there was no documentation of a fall on the date of the incident, and no evidence that the physician or responsible party was notified at that time. Additionally, there was no documentation of range of motion assessment or neuro checks following the incident. The resident later complained of right hip pain to occupational therapy, who then notified nursing. The resident's guardian learned of the fall from the resident's roommate and requested immediate hospital transfer, where a right hip fracture requiring surgical repair was discovered. Interviews with staff revealed that the LPN who found the resident did not notify the physician or responsible party and did not perform a range of motion assessment. The DON confirmed that the facility's expectation was for the physician and responsible party to be notified after any incident once the resident was assessed and safe.