Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident who was found with multiple bruises of unknown origin on her inner thighs and knee. The resident had severely impaired cognition, inattention, and disorganized thinking, making her unable to communicate how the bruises occurred or whether she felt safe. Documentation showed that the incident was discovered by staff in the morning, and while the administrator and DON were notified, the section of the incident report regarding physician notification was left blank. Progress notes indicated that the resident's family was informed, but there was no documentation of immediate provider notification. The physician was not notified until five days after the bruises were discovered, via fax, and was unaware of the incident during a routine visit that occurred in the interim. Interviews with staff confirmed that the expectation was for immediate provider notification, especially given the potential for abuse or injury. The lack of timely communication prevented the physician from evaluating the resident promptly and determining if further medical assessment or interventions were necessary.