Failure to Notify Physician After Resident Injury
Penalty
Summary
Facility staff failed to notify a physician in a timely manner after a television fell from the wall and struck a resident in the arm and head. The resident was assessed as cognitively intact and had a history of Guillain-Barre syndrome and paraplegia. According to the facility's policies, staff are required to notify the physician and document the content of the discussion following any change in patient status or accident. However, nurse notes indicated that although the incident was reported by a CNA, there was no documentation that the physician was notified of the change in condition. Interviews with staff revealed that the RN on duty did not realize the resident had been struck by the television and therefore did not contact the physician. Both the DON and the administrator stated that their expectation is for staff to notify the physician of any accidents, particularly those involving the head, and to document the notification. Despite these expectations and policies, the required physician notification did not occur in this incident.