Failure to Notify Provider of Change in Condition After Fall
Penalty
Summary
The facility failed to immediately notify the physician after a resident experienced a change in condition following a fall. The resident, who was severely cognitively impaired and had diagnoses including metabolic encephalopathy and dementia with behavioral disturbance, had an unwitnessed fall in his room. Initial assessments by nursing staff noted no injuries, and neurological and vital sign checks were initiated as per protocol. However, during these checks, the resident exhibited a low pulse rate of 56 bpm on two occasions, which constituted a change in condition. Despite facility protocols requiring provider notification for such changes, the nurse did not inform the provider at that time. Later in the day, the resident's responsible party identified a hematoma on the resident's head and requested hospital evaluation. The responsible party reported concerns about monitoring and requested to speak with someone in charge. The Director of Nursing was eventually notified and, after discussion, the resident was sent to the hospital. Interviews with staff, the responsible party, and medical providers confirmed that the provider was not notified immediately when the change in condition was first observed, and that the nurse should have reported the low pulse and head injury promptly. Documentation and interviews further revealed that the nurse practitioner and medical director were not made aware of the low pulse readings or the head injury at the time they occurred. Both indicated they would have wanted to be notified immediately to assess the resident and determine if further intervention was needed. The facility's failure to notify the provider of the resident's change in condition after the fall constituted a deficiency in following required notification protocols.