Failure to Notify Family of Resident's Fall, Injury, and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's emergency contact following a series of emergency incidents involving a resident with severe cognitive impairment, including dementia, repeated falls, anxiety, and depression. The resident experienced a fall resulting in a head injury with bleeding, which required immediate transfer to an acute care hospital for evaluation and treatment. Although the physician was notified shortly after the incident, the resident's family was not informed of the fall, injury, or hospital transfer at the time these events occurred. Documentation and interviews revealed that the family only became aware of the incident when the resident was being discharged from the hospital, several hours after the initial event. The facility's policy required notification of the resident's representative in such situations, especially for residents incapable of making decisions. The lack of timely communication left the family unaware of the resident's condition and hospital transfer until after medical intervention had already taken place.