Failure to Notify Physician and Family After Resident Falls and Injuries
Penalty
Summary
Staff failed to notify the physician and family when a resident experienced multiple falls and injuries, including a bruised and swollen hand, skin tears, and abrasions. Documentation in the clinical record showed that after each incident, such as falls and the discovery of new injuries, there was no evidence that the physician or family were informed, nor were follow-up orders or directions obtained from the physician. The facility's own Nursing Standards of Practice required staff to notify the physician of changes in condition and to document follow-up actions, but these steps were not followed. The resident involved had severe cognitive deficits, a history of wandering, and multiple medical diagnoses including cancer, anemia, DVT, BPH, and dementia. Despite being at risk for impaired skin integrity and having a care plan that called for close monitoring, staff did not document required notifications after incidents. Interviews with staff and the administrator confirmed that notifications were not made as required, and that documentation and follow-up were lacking after the resident's injuries and changes in condition.