Failure to Timely Notify Physician and Responsible Parties After Resident Fall
Penalty
Summary
The facility failed to timely notify the physician and other responsible parties of a resident's fall. According to nurse progress notes, a resident was found on the floor early in the morning and assessed by staff, who found no injuries or pain at that time. The resident was assisted back to bed, and the night shift LPN was informed. However, the night shift LPN did not verbally report the fall to the incoming day shift LPN, instead leaving a written note, which was not received. As a result, the day shift LPN was unaware of the fall until a CNA reported swelling and pain in the resident's right leg later that morning. Upon assessment, the day shift LPN noted swelling, pain, and discoloration in the resident's right leg and administered pain relief and an ice pack before contacting the physician. Further review revealed that the night shift LPN did not report the unwitnessed fall to the next shift, nursing management, the physician, or the resident's power of attorney. The resident was later sent to the emergency room, where an X-ray confirmed an acute, displaced fracture of the distal femoral shaft. The Director of Nursing confirmed that the required notifications were not made following the fall, as was necessary.