Failure to Notify Physician and Family After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to immediately notify a resident's physician and family member following an unwitnessed fall that resulted in injury and ultimately the resident's death. The resident, a male with diagnoses including muscle weakness, unsteadiness on feet, cognitive communication deficit, and muscle wasting, was assessed as being at risk for falls and required assistance with mobility. After experiencing an unwitnessed fall, the resident was found with redness on the back of his head and neck, but there was no documented evidence that the physician or family were notified of the incident. Nursing staff involved in the incident did not recall or document notifying the physician or the resident's family member after the fall. The nurse who responded to the fall assessed the resident but did not inquire if the resident had hit his head, nor did she notify the physician or family. Subsequent staff were not informed of the fall, and the resident was later found unresponsive and subsequently passed away after being transported to the hospital. The family was only notified when the resident was being sent to the hospital, and observed injuries at that time. Interviews with facility leadership and staff confirmed that the facility's policy required immediate notification of the physician and family after such incidents, but this was not followed. Documentation related to neurological checks and notifications was incomplete or missing. The physician stated he was not notified of the fall and expected to be informed of such events due to the risk of head trauma. The failure to notify the appropriate parties was identified as an Immediate Jeopardy situation by surveyors.