Failure to Immediately Notify Physician of Resident Fall and Injury
Penalty
Summary
The facility failed to immediately notify the attending physician of an accident resulting in injury for one resident. According to the facility's policy, the charge nurse is responsible for promptly informing the physician of any changes in a resident's condition, including accidents or incidents, and for documenting the details and any instructions received. In this case, a resident experienced a fall at 5:00 a.m. while ambulating to the bathroom. The nurse aide on duty at the time assisted the resident after the fall but did not report the incident to the nursing staff or document it. The fall was only discovered when the resident self-reported the incident to a licensed nurse during the following shift. Subsequent review of the clinical and hospital records indicated that the resident sustained pain in the left elbow, hip, and knee, as well as a left shin skin tear, and reported hitting her head. The physician was eventually notified and ordered x-rays and pain medication, along with treatment for the skin tear. Interviews confirmed that the nurse aide failed to report the fall as required, resulting in a delay in physician notification and assessment. The Director of Nursing verified that the incident was not reported until the resident disclosed it during the next shift.