Failure to Timely Notify Family of Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's family on the same day the resident sustained a fall. The resident, who had diagnoses including heart failure, muscle weakness, difficulty walking, and cellulitis, was admitted from the hospital and was noted to be alert but forgetful and anxious. On the night following admission, the resident was found on the floor next to the bed, appearing confused but without visible injury. The provider was notified promptly, and new safety checks were ordered. However, documentation indicated that the family was not updated about the fall at that time, with a note stating the family needed an update in the morning. A review of the clinical record for the week following the fall showed no evidence that the family was notified until six days after the incident. Facility policy required that family and provider be notified of any falls or changes in condition, and the DON confirmed in an interview that the family should have been notified at the time of the fall. The lack of timely family notification was not in accordance with facility policy or regulatory requirements.