Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and responsible party following an unwitnessed fall involving a resident with a history of falls, muscle weakness, dementia, and abnormal gait and mobility. The resident was assessed as being at risk for falls and was severely impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically indicated that the physician should be notified in the event of a fall. Despite these documented risks and care instructions, the resident experienced an unwitnessed fall, and the incident was not reported to the physician or responsible party until several days later. Record reviews and interviews revealed that the fall occurred in the resident's room, where the resident was found on the floor by an LVN. The LVN did not report the incident to the physician, DON, or responsible party, stating she did not think it was significant. The facility's policy required notification of the physician in the event of an accident or incident of unknown source, but this protocol was not followed. The responsible party confirmed they were not informed of the fall, and the delay in notification was acknowledged by facility leadership during interviews.