Failure to Notify Family of Resident Accident
Penalty
Summary
The facility failed to notify a family member of an accident involving a resident who had a history of falls, impaired cognitive function, and decreased mobility. The resident, who had diagnoses including a pelvic fracture, chronic pain, and unsteadiness, was found on the floor by an LPN after being heard yelling. The resident had visible bruising on the right temple, right arm, and left forearm. Despite the incident and the resident's condition, the family was not notified at the time of the accident. Staff interviews revealed that the LPN who assessed the resident after the fall did not document the assessment, vital signs, or any information about the fall, nor did she notify the family, the administrator, or the DON. The LPN stated she believed another nurse would handle the notifications, but that nurse did not go to the resident's room. The facility's policy requires documentation of the date and time a family member is notified of an accident, which was not followed in this case.