Failure to Notify Families and Representatives of Resident Incidents
Penalty
Summary
Facility staff failed to notify residents, their physicians, and family members or representatives of significant incidents, including falls and an altercation, as required by facility policy. For one resident with cognitive impairment and a diagnosis of dementia, multiple falls and an altercation with another resident were documented in the nurse notes without any evidence that the family or responsible party was informed. The facility's policy mandates notification of family or representatives for incidents such as accidents, injuries, or significant changes in condition, and requires documentation of such notifications in the resident record. However, review of the records showed repeated omissions of this documentation, and the resident's legal guardian confirmed not being informed about these events. Similarly, another resident with a history of stroke and dementia experienced multiple falls, but there was no documentation that the family or representative was notified, despite the presence of emergency contacts and a power of attorney on file. Interviews with nursing staff and the administrator confirmed that nurses are responsible for notifying families and documenting these notifications, but staff admitted to not completing these tasks due to being busy. The administrator was unaware that families were not being informed as required.