Failure to Notify Resident Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident representative of a fall sustained by a resident. Record review showed that the resident experienced a fall, which was documented on an SBAR Communication form. The form indicated that the resident's representative was listed as the emergency contact, but no phone numbers were provided for either the representative or the resident's daughter, making it impossible to contact the family. The form was signed by an LPN, but there was no documentation that the family had been notified of the incident. Interviews revealed that the resident's granddaughter was not informed of the fall at the time it occurred. She discovered her grandmother's injuries upon visiting and subsequently contacted the unit manager via facetime, at which point she was informed of the fall. The LPN involved stated that she did not know about the fall until checking the computer after being contacted by the granddaughter. Another LPN could not recall if the family had been contacted. Facility policy requires prompt notification of the resident representative and attending physician in the event of accidents, but this procedure was not followed in this case.