Failure to Timely Notify Responsible Party After Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to notify the responsible party in a timely manner following a significant change in condition for a resident with dementia and severe cognitive impairment. The resident, who was at risk for falls and required specific interventions such as wearing grippy socks, experienced a witnessed fall resulting in a head laceration and a change in level of consciousness. Emergency services were called, and the resident was transferred to the hospital. Documentation showed that the provider was notified at 5:15 AM, but the responsible party was only left a voicemail at 9 AM, with no evidence of further attempts to reach them. Interviews with nursing staff revealed inconsistencies and lack of clarity regarding who was responsible for notifying the family, with some staff assuming others had made the call. The facility's policies required timely notification and documentation of all attempts to contact the responsible party, especially after a serious injury. However, the clinical record and interviews confirmed that only a single voicemail was left, and no additional follow-up or documentation of further attempts was found.