Failure to Timely Notify Physician and Representative of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and resident representative in a timely manner following the discovery of a new skin tear injury. The resident, who had a history of traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and severely impaired cognition, was found to have a skin tear on the left lower shin while being assisted by staff. The injury was assessed and treated by a registered nurse, but the physician was not notified until two days later, and there was no evidence that the resident's representative was notified at the time of the incident. Documentation showed that the resident's representative only learned of the injury later in the day after inquiring about a bruise, and the physician's office confirmed delayed notification. Interviews with staff and review of facility procedures revealed that staff were expected to notify the physician and resident representative immediately or within the same shift when new injuries occurred. However, the nurse who discovered the injury did not complete the required notifications, citing a busy shift and incomplete charting. The incident report was not completed until later, and the facility was unable to provide a copy of its notification policy when requested. This failure to promptly notify the appropriate parties constituted a deficiency in the facility's response to resident injuries.