Failure to Notify Physician and Inadequate Staff Training Following Unwitnessed Fall
Penalty
Summary
The facility failed to notify the physician in a timely manner following an unwitnessed fall with potential head injury involving a resident with multiple complex medical conditions, including quadriplegia, diabetes, and acute kidney failure. The resident was found on the floor by a registered nurse, who performed an assessment and left a message for the physician but did not speak directly with them. The nurse also notified the resident's guardian and monitored the resident throughout the shift, but did not follow up with the physician after the initial message, as there were no observed changes in the resident's condition at that time. The facility's policy required physician notification after an accident or incident, but documentation in the medical record did not show direct communication or a physician assessment regarding the fall. The facility's policies and protocols did not provide clear guidance on the management of unwitnessed falls, particularly regarding residents not on anticoagulant therapy. Interviews with staff, including the DON and the administrator, confirmed that there was no specific written policy addressing unwitnessed falls or the protocol for sending residents out for evaluation based on anticoagulation status. The only available policy, "Fall Prevention and Management," did not address these scenarios, and staff relied on state guidelines and their own clinical judgment. The lack of a clear protocol contributed to inconsistent practices and uncertainty among staff regarding appropriate actions following unwitnessed falls. Additionally, the facility failed to properly in-service staff on Fall Risk Assessments. The in-service documentation provided did not include the date, time, or specific educational content covered, making it unclear whether staff received adequate training on fall risk identification and management. This deficiency in staff education, combined with the lack of clear protocols, had the potential to affect all residents in the facility, as proper fall risk assessment and response are critical for resident safety.