Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify a resident's responsible party following an unwitnessed fall that resulted in an abrasion. The resident, who had a history of left femur fracture, diabetes mellitus type II, osteoarthritis, moderate cognitive impairment, and functional limitations, experienced a fall in her room early in the morning. Documentation indicated that the responsible party was notified shortly after the incident; however, nursing progress notes later revealed that attempts to contact the responsible party were unsuccessful due to a reported busy signal. The responsible party later stated she was not contacted and only learned of the fall several days later when the resident complained of pain. Interviews with facility staff confirmed that the night nurse was unable to reach the responsible party and passed the information to the ADON, who also failed to make successful contact and did not ensure follow-up. The responsible party clarified that she only uses a cell phone, which does not produce a busy signal, suggesting the wrong number may have been used. Facility policy requires notification of significant changes in resident status to the responsible party, but this was not achieved in this instance.