Failure to Notify Responsible Party of Resident Fall with Injury
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's fall with injury. The resident, who had severely impaired cognitive skills and multiple diagnoses including diabetes, chronic kidney disease, osteoporosis, hypertension, depression, and gastroesophageal reflux disease, was found on the floor with a skin tear on the right elbow. The nurse assessed the resident, notified the unit manager and nurse practitioner, and obtained treatment orders, but did not notify the resident's family or responsible party as required. The nurse believed the resident was her own responsible party and did not contact the emergency contact listed in the records. Review of the clinical record confirmed there was no documentation of family notification regarding the fall. Interviews with the nurse, unit manager, and administrator all confirmed that the family was not notified of the incident and that this was not handled according to facility policy, which requires responsible party notification in the event of a change in condition. The deficiency was identified through staff interviews, facility document review, and clinical record review.