Failure to Notify Resident Representative and Hospice Provider After Incident
Penalty
Summary
The facility failed to ensure that required notifications were made to a resident's representative and hospice provider following an incident in which the resident was lowered to the ground during care. The resident involved had a history of dementia, type II diabetes, a recent right femur fracture, generalized anxiety disorder, major depressive disorder, anemia, and a terminal diagnosis of rectal cancer. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and was receiving hospice care at the time of the incident. On the day of the incident, staff were providing wound care to the resident using a stand-up lift. During the process, the resident became restless and managed to remove his arm from the sling, resulting in staff lowering him to the floor for safety. The resident then flung his body to the side before staff could unstrap his legs from the lift. He was subsequently assisted back into his wheelchair, and no injuries or pain were noted at the time. Documentation confirmed that the resident's physician was notified of the incident, but there was no evidence that the resident's spouse or hospice provider were informed. Interviews with staff involved in the incident, including a registered nurse and a licensed practical nurse, confirmed that neither the resident's family nor hospice provider were notified about the event. Review of facility policies indicated that it was required to notify the resident, physician, and resident representative in the event of an accident or significant change in status. The lack of documentation and staff confirmation established that the required notifications were not made following the incident.