Failure to Notify Physician and Conduct Monitoring After Resident Incidents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for one resident. The facility did not ensure timely physician notification when a resident's representative reported that the resident was tied to a wheelchair with a bedsheet and alleged that a CNA hit and kicked the resident. The incident was reported to the primary care clinician approximately seven hours after it was brought to the attention of facility staff, despite facility policy requiring prompt notification in urgent situations. The Director of Nursing confirmed that the physician notification was not timely. Additionally, the facility did not notify the physician or the resident's representative when the resident was found on the floor with purplish discoloration on the left thigh, following an unwitnessed fall. Facility policy required follow-up and monitoring, including neurological assessments after unwitnessed falls or injuries involving possible head trauma. However, neither neurological monitoring nor timely notifications were conducted or documented. Both LVNs involved in the incident confirmed that the physician and resident representative were not notified, and neurological evaluation was not initiated. The resident involved had a history of moderate cognitive impairment and required maximum staff assistance for activities of daily living. Medical records indicated the resident was capable of understanding and making decisions. The failures to notify the physician and representative, and to conduct appropriate monitoring after significant incidents, were verified by the Director of Nursing and were not in accordance with the facility's policies and procedures.