Failure to Notify Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead. The resident, who had a history of traumatic subdural hemorrhage, atrial fibrillation, congestive heart failure, and was on anticoagulation therapy, was found on the floor with purple lumps on the forehead and a small skin tear on the left wrist. The RN on duty performed an assessment, provided basic wound care, and notified the Executive Director, Resident Care Manager, Nurse Practitioner (NP), and Guardian, but did not contact the on-call medical provider at the time of the incident. The resident was monitored, and pain medication was administered. Later, during the day shift, an LPN noticed additional bruising and changes in the resident's cognition and reached out to the NP, who then assessed the resident and decided to send the resident to the emergency department for further evaluation due to the high risk associated with anticoagulation. Review of facility documentation and interviews confirmed that the NP was not notified of the fall and injury until the day shift, several hours after the incident. The facility lacked a clear policy for physician notification related to change of condition, and the relevant fall management policy did not specify provider notification requirements.