Failure to Notify Responsible Party of Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure timely and proper notification to a resident's responsible party regarding changes in condition, specifically related to multiple falls and subsequent injuries. The resident, who was severely cognitively impaired with a BIMS score of 3 and diagnoses including dementia and anxiety, experienced several unwitnessed falls over a period of weeks. Documentation revealed that the resident sustained injuries such as bruises and a hematoma, but these were not consistently or promptly communicated to the family member. The family member reported being notified of falls and injuries several days after the events, or not at all, and was unaware of significant injuries until the resident exhibited severe pain. Staff interviews confirmed that falls were sometimes not documented, and that incident reports did not always reflect the presence of injuries. On one occasion, a large bruise and a hematoma were discovered, but the findings were not reported to the provider or the family member. The family member only learned of the injury when an x-ray was ordered, leading to confusion and distress. Nursing notes corroborated the family member's concerns about lack of communication regarding the resident's pain and injuries.