Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and end stage renal failure requiring dialysis, was found on the bathroom floor after not locking their wheelchair. The resident was assessed by nursing staff, found to be stable, alert, and oriented, with no pain or neurological changes. Documentation showed that the medical doctor was notified, but there was no evidence that the resident's representative was informed of the incident. Interviews with nursing staff and facility leadership confirmed that the expected protocol was to notify the physician and the resident's representative after a fall and to document these notifications in the progress notes. However, the administrator acknowledged that there was no documentation to show the family had been notified following the fall, indicating a failure to follow the facility's notification procedures.