Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to immediately notify a resident's representative after the resident experienced an unwitnessed fall that resulted in injury and had the potential for requiring physician intervention. The resident, an elderly male with diagnoses including unspecified dementia, hypertension, congestive heart failure, and metastatic prostate cancer, had a history of falls and was assessed as having moderately impaired cognition. On the day of the incident, the resident was found on the floor of his restroom after standing up from the toilet and experiencing weakness in his legs, leading to a fall. The nurse on duty assessed the resident, noted multiple skin tears, and initiated fall protocol and neurochecks. The nurse notified the on-call nurse practitioner and the assistant director of nursing but did not notify the resident's family member or representative. The resident's family member, who was listed as the emergency contact, was not informed of the fall by the facility. Instead, the family member learned of the incident directly from the resident the following morning, who described the fall and his pain. When the family member contacted the facility, the nurse confirmed the fall had occurred the previous day. Interviews with facility staff, including the LVN, RN, DON, ADON, and administrator, revealed that the expectation was for the family or emergency contact to be notified of any significant change, such as a fall, regardless of the resident's status as their own responsible party. The staff member involved stated she did not notify the family because she believed the resident was his own responsible party. Review of facility policies and in-service training materials confirmed that both the provider and the resident's representative should be notified of a fall, with documentation of the date and time of notification. The failure to notify the resident's representative was inconsistent with facility policy and staff training, as well as the expectations of facility leadership.