Failure to Timely Notify Emergency Contact After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's emergency contact in a timely manner following an incident where the resident's knees buckled, resulting in staff lowering the resident to the ground in the shower room. The resident, who had a history of falls, cerebral infarction, and cognitive communication deficit, was found on the floor but denied pain or injury at the time. Documentation showed that the nurse and staff assisted the resident back into a wheelchair and noted that all appropriate parties were notified, but did not specify who was contacted or when. Further review of the incident report revealed that the resident's family member, listed as the emergency contact, was not notified until several hours after the incident. The physician was also notified later in the day. There was no documentation in the progress notes indicating immediate notification of the family member or emergency contact after the fall. The delay in notification became apparent when the family member, during a doctor appointment with the resident, learned of the incident and subsequently took the resident to the emergency room, where a right knee fracture was diagnosed. Interviews with facility staff confirmed that the assigned nurse did not notify the family member immediately after the incident, and that documentation of such notifications was lacking. The facility's policy on notification of change was requested but not provided at the time of the survey exit. Staff interviews indicated an expectation that the charge nurse or unit ADON would be responsible for timely notification and documentation, but this did not occur in this case.