Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
Licensed Vocational Nurse 4 (LVN 4) failed to immediately notify the physician and family after a resident experienced an unwitnessed fall. The resident, who had diagnoses including osteoarthritis, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for activities of daily living. On the evening of the incident, the resident was found on the floor mat by the bed and was assisted back to bed by LVN 4, LVN 3, and a CNA. LVN 4 did not document the fall or notify anyone, stating that there was no injury or distress observed at the time. Subsequent reviews of the resident's records showed that neither the physician nor the family were informed of the fall until several days later, after further changes in the resident's condition were noted, including swelling, discoloration, and eventually fractures requiring surgical intervention. The facility's policy required immediate notification of the physician and family in the event of an incident or accident involving a resident. The Director of Nursing confirmed that the policy applied to this situation and that the required notifications were not made at the time of the fall.