Failure to Notify Physician and Resident Representative After Resident Fall
Penalty
Summary
The facility failed to notify the medical doctor and the resident representative after a resident experienced a fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left in the dining room entrance by a CNA, and subsequently found on the floor by staff. Multiple staff interviews confirmed the fall occurred, but there was no immediate documentation or notification to the physician or resident representative. A review of the electronic medical record revealed that a Change in Condition (COC) assessment was not completed on the day of the fall, and was only created several days later. The Director of Nursing confirmed that the COC should have been completed during the same shift as the incident, and that the required 72-hour monitoring and care plan updates were not performed until a week after the fall. There was also no evidence that the physician or resident representative were notified at the time of the incident. Facility policies require prompt documentation and notification following a change in condition or incident, including notifying the physician and family, completing a COC assessment, and implementing monitoring. The lack of timely documentation and notification was confirmed by both record review and staff interviews, indicating a failure to follow established procedures after the resident's fall.