Failure to Notify Family and Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify a resident's representative and medical provider following a fall with potential injury. The resident, who had diagnoses including dementia with agitation, psychosis, anxiety, and delusional disorder, experienced a fall during a power outage and was found on the floor with pain in the left leg. Documentation indicated that the administrator and DON were notified, and an information sheet was prepared for the certified nurse practitioner (CNP). However, the progress notes stated that the resident's family would be notified during business hours, and there was no follow-up documentation confirming that the family was actually notified after the first fall. The family member later reported learning about the first fall only after being notified of a second fall the following day. After the falls, the resident exhibited increased pain and inability to bear weight on the left leg. Hospice was notified and recommended comfort measures, including morphine administration, but there was no documentation that the CNP was updated about the resident's ongoing pain and weight-bearing difficulties as previously ordered. The CNP later stated that if she had been informed of these changes, she would have considered ordering an x-ray and discussing options with the family. The family was not given the opportunity to decide on further diagnostic evaluation, such as an x-ray, despite the resident's worsening condition. The facility's own policy required immediate notification of the resident, physician, and representative in the event of an accident with potential injury or significant change in condition. Interviews with staff and review of documentation confirmed that there was no evidence the family or CNP were properly notified as required. The resident's condition deteriorated following the falls, and he passed away a few days later. The lack of timely notification and communication with both the family and medical provider constituted the deficiency identified by surveyors.