Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to notify the physician of a resident's fall, as required by policy. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and impaired cognition, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, but there was no documentation in the medical record indicating that the physician was notified of the incident. Interviews with nursing staff, the Director of Nursing, and the resident's son confirmed that the fall occurred and that the physician and nurse practitioner were not informed at the time of the event. Further interviews with the nurse practitioner and physician revealed that neither was aware of the fall until several days later. Review of the facility's policy on changes in a resident's condition or status indicated that the nurse supervisor or charge nurse is responsible for notifying the attending physician or nurse practitioner in the event of an accident or injury. The lack of timely notification to the physician following the resident's fall constituted a deficiency as identified during the complaint investigation.