Failure to Notify Resident Representative After Injury
Penalty
Summary
The facility failed to notify the family member or resident representative of an accident involving a resident who was struck in the eye area by a mechanical lift handle, resulting in a skin tear with minor bleeding that required a wound covering. The incident occurred during a transfer performed by two nurse aides, who immediately notified the hall nurse. The nurse assessed and treated the wound, but did not document any notification to the resident's family or representative. The incident report included designated sections for recording family notification, but these were left blank by the nurse who completed the report. The resident, who was cognitively intact and had multiple medical diagnoses including epilepsy, diabetes, heart disease, and hypertension, was unaware if his family had been informed of the incident. Interviews with the nurse aides involved confirmed that they believed it was the nurse's responsibility to notify the family and that they did not make any such notification themselves. Attempts to interview the nurse responsible and the family member were unsuccessful. The former Director of Nursing recalled the incident and stated that staff were expected to complete the incident report fully, including family notification, but acknowledged that the lack of documentation indicated the family was likely not notified. The deficiency centers on the facility's failure to ensure timely notification to the resident's representative following an accident resulting in injury.