Delayed Notification of Responsible Party After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a resident's Responsible Party (RP) of a significant change in condition following a fall. The resident, who had dementia and was severely cognitively impaired, was found on the floor by a Certified Nurse Assistant at 4:39 a.m. The facility's records show that the RP was not notified until 7:00 a.m., resulting in an approximately two-and-a-half-hour delay. The facility's policy required immediate notification of the resident representative in the event of an accident involving the resident. Interviews revealed that the Licensed Vocational Nurse (LVN) who discovered the fall was hesitant to report the incident to the RP and required guidance from the Director of Nursing (DON) to complete post-fall procedures. The DON confirmed that the RP should have been notified at the time of the incident, in accordance with facility policy. The delay in notification was confirmed by both the RP and facility staff during interviews and record review.