Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to notify both the physician and the resident's representative following a fall involving a resident with cognitive impairment and multiple medical diagnoses, including dementia, diabetes, chronic kidney disease, and hypertension. According to facility policy, after a fall, the licensed nurse is required to assess the resident, initiate SBAR communication, and notify the physician and responsible party. However, documentation and interviews revealed that after the resident was found on the floor between the bed and the wall, there was no evidence that the physician or the resident's representative was contacted regarding the incident. Staff interviews confirmed that the charge nurse was informed of the fall, but neither the physician nor the resident's family was notified as required. The resident's care plan specifically included interventions to notify both parties in the event of a fall. The Director of Nursing acknowledged that the charge nurse did not fulfill these responsibilities, and the progress notes lacked documentation of any notifications being made.