Failure to Notify Responsible Party After Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition following a fall and subsequent emergent transfer to the hospital. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), Alzheimer's Disease, and a neck fracture, was deemed unable to make her own medical decisions, with her family member documented as her legal decision maker. After the resident experienced a fall, the assigned LPN was notified by a CNA, and the resident reported severe head pain. The LPN contacted the attending physician, received an order to transfer the resident to the hospital, and arranged for EMS transport. However, there was no documentation that the resident's responsible party was informed of the fall or the hospital transfer at the time of the incident. The responsible party only became aware of the situation when contacted by the emergency room physician later that day. Facility records, including progress notes and a concern form, confirmed the lack of timely notification to the responsible party. The facility's policy required prompt communication of such events to both the attending physician and the resident's legal representative, but this was not followed in this instance. Interviews with the LPN involved revealed uncertainty about whether the notification was made and a lack of recall regarding any related education or disciplinary action.