Failure to Notify Physician and Resident Representative After Reported Fall
Penalty
Summary
A deficiency was identified when a resident reported a fall and subsequent pain to a Certified Occupational Therapist Assistant (COTA) during a therapy session. The COTA relayed this information to the assigned LPN, who assessed the resident and found no visible injury or change in condition. The LPN applied lidocaine cream to the resident's left arm dialysis site as per routine orders and sent the resident to their scheduled dialysis session without further action. Later, the dialysis center contacted the facility to report that the resident had facial bruising and was being transferred to the emergency room for evaluation. Review of facility documentation and interviews revealed that the LPN did not initiate the facility's fall protocol, which includes conducting a thorough investigation, notifying the supervisor, the physician, and the resident representative (RR), and updating the care plan. There was no documentation that the physician or RR was informed at the time the fall was reported. The resident involved had severe cognitive impairment, end stage renal disease, and was dependent on hemodialysis. Despite the resident's report of a fall and complaint of pain, the required notifications and protocols were not followed, as confirmed by staff interviews and review of facility policy, which mandates timely notification of the physician and family after such incidents.