Failure to Notify Resident Representative of Injury and Fall
Penalty
Summary
The facility failed to notify a resident's representative of an injury and an unwitnessed fall, as required by policy. The resident, who had severe cognitive impairment and required maximum assistance, was observed with multiple bruises and discoloration on her body over several days. Progress notes and staff interviews confirmed that these injuries were documented, and an unwitnessed fall occurred, but there was no documentation or evidence that the family was notified promptly after these incidents. Staff interviews revealed that the nurse responsible did not notify the family or supervisors immediately after the fall, citing the end of shift and being off over the weekend as reasons for the delay. The resident's representative confirmed that notification was only received from hospice staff several days later, not from the facility. Facility policy requires immediate notification of the resident's physician and family following incidents such as falls or injuries, and documentation of such notifications in the medical record. Despite this, the required notifications were not made in a timely manner, and the incident was not properly documented according to policy. The deficiency was identified through closed record review, staff interviews, and review of facility documentation, which all indicated a lapse in communication and adherence to established procedures for reporting resident injuries and incidents.