Failure to Timely Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a physician following a resident's change in condition after a fall. According to the facility's policy, licensed nurses are required to promptly assess and notify the physician and family when a resident experiences a change in condition. In the case reviewed, a resident with severe cognitive impairment, high risk for falls, and multiple diagnoses including anxiety, muscle weakness, and hypertension, experienced an unwitnessed fall while attempting to transfer from the toilet. The resident sustained a skin tear and reported pain and dizziness. Although the incident was documented and the resident's family was eventually notified, the physician was not informed until three days after the fall, and the family was notified twenty days later, contrary to facility policy and regulatory requirements. Staff interviews confirmed that the expected protocol was immediate notification of both the physician and family following such incidents. Documentation revealed inconsistencies in communication and a lack of timely documentation regarding the incident and subsequent actions. The failure to notify the physician and family in a timely manner was acknowledged by both nursing staff and the facility administrator, confirming noncompliance with established resident care policies and state regulations.