Failure to Notify Emergency Contact After Resident Falls
Penalty
Summary
The facility failed to notify a resident's emergency contact or representative following two separate unwitnessed falls that occurred on 6/30/25 and 7/12/25. According to the facility's policy, any change of condition, including falls, requires timely notification of the resident's representative. Review of the electronic medical record and fall investigations revealed no documentation that the resident's wife or emergency contact was informed of either incident or the potential change in condition. The resident, who had a history of hemiplegia, atherosclerotic heart disease, chronic kidney disease, COPD, epilepsy, anemia, dysphagia, and depression, was assessed as moderately impaired in daily decision-making but was alert and oriented at the time of surveyor interviews. During interviews, the resident expressed that his wife should be notified of all events at the facility. The DON stated that notification was not necessary because the resident was considered his own person at the time, but there was no documentation indicating the resident declined notification of his emergency contact. The surveyor confirmed with facility leadership that there was no evidence or explanation provided for the lack of notification, despite facility policy requiring it.