Failure to Promptly Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly identify and notify the physician and responsible party of a change in condition for a resident who experienced a fall resulting in new onset pain. According to the facility's policy, any accident involving a resident that results in injury requiring provider intervention, or a significant change in the resident's physical, mental, or psychosocial status, requires immediate assessment and notification of the primary provider, resident representative, and the resident. In this case, the resident, who had a history of dementia, parkinsonism, hearing loss, osteoporosis, and traumatic brain injury, fell from her chair and landed on her left side. Staff observed the resident in pain, crying, and expressing discomfort during and after being assisted back into her chair and later transferred to bed. Despite clear signs of pain and distress, the licensed nurse on duty did not notify the primary physician or the resident's responsible party at the time of the incident. Instead, the nurse waited until the end of her shift to send an email to the medical director, resulting in an eight-hour delay before the physician was made aware of the situation. The physician reported that the initial notification lacked critical details, such as the time of the incident and a proper assessment, and was not informed that the resident had fallen or was experiencing pain with movement. The responsible party was also not notified until later in the evening, just before the resident was sent to the emergency department. Documentation review revealed that required notifications to the physician and family were not completed or documented as done on the facility's alert charting forms. The director of nursing confirmed that there was no documentation of timely notification to the primary physician or responsible party following the change in the resident's condition. The delay in notification and treatment resulted in the resident experiencing unnecessary pain and suffering, and subsequent evaluation in the emergency department revealed an acute displaced subcapital left femoral neck fracture.