Failure to Notify Resident Representative of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to notify a resident's representative of the resident's involvement in a resident-to-resident altercation, as required by facility policy. The incident involved a resident with Alzheimer's, vascular dementia, and dysphagia, who was pushed in the back by another resident while attempting to access a food cart. No injuries were noted. Review of the resident's records, including progress notes and the electronic health record, revealed no documentation that the resident's representative was informed of the incident. There was also no SBAR documentation related to the event. Interviews with the resident's representative confirmed that neither he nor his wife had been notified of the altercation. Facility staff, including an LPN, acknowledged the absence of documentation and notification, and the DON and Administrator stated that it was their expectation for staff to notify the resident's representative and document such incidents. The nurse responsible for the resident at the time did not follow this protocol, resulting in the deficiency.