Failure to Notify Guardian of Resident Injury and Hospitalization
Penalty
Summary
The facility failed to notify a resident's legal guardian regarding the extent of injuries and subsequent medical interventions following a physical altercation with another resident. After the incident, the resident was found on the floor with visible injuries, including red marks on the forehead and right elbow, and reported significant pain and inability to bend the right elbow. The resident was transferred by ambulance to a hospital for evaluation, where a nondisplaced spiral fracture of the right humerus was diagnosed, and surgical repair was recommended. Although a staff member stated that a voicemail was left for the guardian about the altercation and transfer, the guardian and the on-call emergency contact both reported not receiving any notification or voicemail regarding the incident, the transfer, or the diagnosis. Facility policy requires prompt notification of the resident's representative in the event of significant changes, such as accidents resulting in injury, transfers, or the need for surgical intervention. Record review showed no evidence that the guardian was informed about the transfer, the results of the hospital evaluation, or the need for surgery. Interviews confirmed that the guardian expected immediate notification of such events and would have contacted the resident if informed. The administrator also confirmed that staff are expected to follow the notification policy, which was not adhered to in this case.