Failure to Timely Notify Family of Resident's Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative or family member of a significant change in condition and transfer to the Emergency Department (ED) following a fall from a full body mechanical lift. The resident, who had no cognitive impairment and required maximum assistance for transfers, experienced a fall that resulted in serious injuries, including a neck fracture, thoracic compression fracture, and bleeding around the brain. Although the physician was notified of the fall, staff did not immediately notify the resident's family or Power of Attorney (POA) due to the absence of a phone number on the transfer paperwork. The Director of Nursing (DON) later located the contact information and notified the family, but this occurred approximately two hours after the incident. Interviews with staff and the resident's family confirmed that the family was not informed of the fall or the transfer to the ED until after the DON came on shift and made the call. The family member reported not receiving any missed calls from the facility and only learned of the incident after being prompted by hospital staff. Facility policy required immediate notification of family or POA in the event of emergency incidents, but this expectation was not met in this case, as documentation and staff interviews confirmed the delay in notification.