Failure to Notify Physician and Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident's physician and emergency contact or representative after the resident experienced a fall and hit his head. The resident, who had multiple diagnoses including sick sinus syndrome, syncope, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident, and hypertension, had recently received a pacemaker. On the evening of the incident, the resident fell in the shower room, hitting his head on both the wall and the floor. Emergency Medical Technicians were called to assist due to the recent pacemaker placement, and the Director of Nursing was notified. However, there was no documentation that the resident's physician or emergency contact was informed of the fall. Interviews with staff confirmed that the CNA reported the fall and head injury to the LPN on duty, but the LPN did not notify the physician or the resident's representative. The LPN stated she was overwhelmed by another emergency at the time and could not explain why the notifications were not made. The resident's emergency contact also confirmed that she was not informed of the incident. Facility policies required timely notification of the physician and family after a fall, and documentation of the date and time of such notifications, but these procedures were not followed in this case.