Delayed Notification to Resident Representative After Significant Fall
Penalty
Summary
Facility staff failed to immediately notify the resident representative of a significant change in condition following a fall involving a resident with multiple complex diagnoses, including chronic atrial fibrillation, COPD, Alzheimer's disease, and a history of repeated falls and fractures. The resident, who had moderate cognitive impairment and required substantial assistance with mobility and hygiene, was found by a CNA lying on the bathroom floor without nonskid footwear, having sustained multiple skin tears, discoloration to the cheek, and complaining of left arm and elbow pain. The incident occurred in the morning, and the physician was notified promptly, with x-rays ordered for the affected areas. Despite the resident's evident pain and the presence of substantial injury, documentation and staff interviews revealed that the resident representative was not notified of the fall until several hours later, around midday. Multiple staff members, including the CNA, DOR, and LPN, confirmed that the notification to the family did not occur immediately, with the LPN stating that the delay was due to prioritizing patient care and other pressing issues. The resident's sister was present in the facility later that day and expressed concern about the delay in notification, though ultimately did not file a grievance. The facility's documentation, including the Fall Investigation Form and Change in Condition document, corroborated the timeline of the fall and the delayed notification to the resident representative. Staff interviews consistently indicated that the family was not informed until after lunch, despite the resident's significant pain and the need for medical intervention. The deficiency centers on the failure to promptly communicate a significant change in the resident's condition to the designated representative as required.