Failure to Immediately Notify Resident Representative After Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's representative of a change in the resident's condition following a fall. The resident, a male with a history of orthopedic aftercare following a surgical amputation, acquired absence of the left leg below the knee, and dysphagia, was assessed as having moderately impaired cognition. On the date of the incident, the resident experienced a fall during a sliding board transfer, resulting in minor skin tears to his right hand. The incident was witnessed by a CNA, and the resident was assessed and treated by an LVN, who then sent the resident to dialysis as scheduled. Despite the facility's policy requiring prompt notification of the resident's representative in the event of an accident or injury, the LVN did not notify the family on the day of the fall. The LVN later stated that she believed the resident had informed his family during a phone call and admitted that the notification slipped her mind due to being approached by another resident's family after the incident. The family only became aware of the fall after noticing a bandage during a video call with the resident the following day, prompting them to contact the facility for information. Interviews with facility staff, including the LVN, DON, and administrator, confirmed that the charge nurse was responsible for notifying families of falls or changes in condition. The facility's documentation and inservice training records indicated that staff had been trained on notification protocols, but the LVN could not recall the specific training date. The DON and administrator acknowledged that the family should have been notified immediately, as per facility policy, but were unable to provide reasons for the delay in this instance.