Failure to Notify Resident Representative of Multiple Falls
Penalty
Summary
The facility failed to notify the resident representative of multiple falls experienced by a resident who had a history of stroke with hemiplegia and severe cognitive impairment. The resident required substantial assistance for bed mobility and transfers. According to interviews and record reviews, the resident's representative was only informed of one fall, despite the resident having experienced five falls during their stay. The representative stated they were present daily and were unaware of the additional incidents until a discharge meeting with staff. Review of incident reports revealed that notifications to the family and physician were inconsistently documented. In some cases, the reports indicated that notifications were made after a delay, while in others, there was no evidence of notification at all. Staff responsible for reviewing the incident reports acknowledged that they did not personally contact the family and relied on assumptions or secondhand information regarding whether notifications had occurred, particularly for falls that happened during night shifts.