Failure to Notify Responsible Party and Physician of Resident Altercation and Injuries
Penalty
Summary
The facility failed to notify the responsible party (RP) and the physician when a resident was involved in a resident-to-resident altercation and subsequently sustained visible injuries, including a cut under the left eye, bruising on the left cheek, and scabs to the left side of the nose and under the left eyebrow. Despite documentation indicating that the RP was notified, interviews with staff and the RP revealed that the notification did not occur as required. The RP only became aware of the injuries during a visit and was not informed about the altercation or the resulting wounds. Staff interviews further confirmed confusion and lack of clarity regarding who was responsible for notifying the RP, with documentation not matching actual communication events. Additionally, the facility did not assess, treat, or monitor the resident's injuries in accordance with its own policies. The ADON and Administrator were unaware of the full extent of the resident's injuries until they were observed during a visit, and there was no documentation of assessment, treatment, or physician notification regarding the wounds. The facility's policies required notification of changes in condition, accidents, and new treatments, but these procedures were not followed in this instance.