Failure to Notify Family and Physician of Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify both the family and physician of a resident's fall. The resident, who had multiple diagnoses including chronic diastolic congestive heart failure, diabetes, hypertension, and dementia, was admitted with significant cognitive and physical impairments, requiring staff assistance for most activities of daily living. On the date of the incident, the resident's daughter, who monitored her mother via an electronic camera, observed her mother on the floor and reported not receiving any notification from the facility about the fall. The Director of Nursing (DON) confirmed that the daughter presented video evidence of the fall, and the nurse involved gave inconsistent accounts regarding whether the family was notified, including stating that he was told not to call the family and later claiming to have sent a text, which the daughter did not receive. Review of the medical record showed no documentation of the fall on the date it occurred, and a late entry was made several days later, indicating the resident was found slanted in her wheelchair and that the daughter was texted. However, there was no evidence that the physician was notified of the fall, as required by the facility's policy on notification of changes in condition. The DON verified that there was no documentation of physician notification and acknowledged the inconsistencies in the nurse's account of family notification.