Failure to Timely Notify Provider After Resident Fall and Condition Decline
Penalty
Summary
Nursing staff failed to notify the resident's provider in a timely manner following an unwitnessed fall and episode of emesis during the overnight shift. The resident, who had a history of diabetes, difficulty walking, sleep apnea, and schizoaffective disorder, was found on the floor in emesis at approximately 2:00 A.M. by nursing staff. The nurse assessed the resident, determined there were no complaints of pain, and initiated neurological monitoring, but did not notify the provider of the incident at that time. Later in the morning, the resident reported feeling unwell and weak to a CNA, who relayed this information to the nurse. At around 8:00 A.M., the nurse found the resident to be unrousable but breathing, indicating a decline in condition. Despite these significant changes, there was no documentation that the provider was notified until approximately 9:00 A.M., when the nursing supervisor was informed and subsequently contacted the provider, who ordered the resident to be sent to the hospital emergency department. Interviews with staff confirmed that the nurse did not notify the on-call provider during the overnight shift regarding the fall, emesis, or the resident's subsequent decline. The facility's policy required prompt notification of the provider in the event of a significant change in condition, which was not followed in this case. Documentation and staff statements corroborated that the required notifications were delayed.