Failure to Notify Guardian of Resident Fall and Change in Condition
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, experienced a fall with injury. The resident, who had diagnoses including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and urinary tract infection, was found on the floor next to the bed, entangled in bedding, with a bruise on the right temporal region and stool present on the chest and bed. The resident was unresponsive to questions and refused to open their mouth for medications. Neuro checks were completed with no concerns noted at the time. Despite facility policy requiring notification of the physician and family or responsible party after a fall, the resident's Guardian, who had been appointed prior to the incident, was not informed of the fall or the resulting injury. The Guardian only became aware of the bruise during a subsequent visit and had not been notified by staff. The Director of Nursing confirmed that the Guardian should have been notified of the fall and change in condition, but this did not occur.