Failure to Notify Power of Attorney After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Healthcare Power of Attorney (HPOA), who is also the resident's daughter, after the resident experienced a fall from her bed. The resident's face sheet identified her daughter as the HPOA. According to the progress note, the resident fell out of bed at 2:00 AM and was assessed by a nurse, who found no injuries. The nurse documented an intention to call the HPOA around 6:00 AM but did not follow through with the notification. The HPOA was not informed of the fall by facility staff and instead learned about the incident from the resident's sister, who had visited and been told about the fall by the resident herself. During interviews, the HPOA expressed frustration at not being notified immediately, stating her expectation to be informed of any changes regardless of the time. The nurse later acknowledged forgetting to call the HPOA and believed another nurse may have notified her later that day. The Director of Nursing confirmed that family should be notified immediately of any changes in condition, including falls, and that notification is important for informed decision-making. The facility's policy also requires notification of both the physician and the POA following a resident fall.