Failure to Notify Physician and Family After Resident Falls
Penalty
Summary
The facility failed to notify residents' families and physicians of changes in condition and incidents, specifically regarding falls, in a timely manner for two residents. Documentation revealed that after multiple falls, staff did not consistently notify the physician or family, nor did they always document these notifications. In several instances, falls were either not documented at all or lacked clear records of physician and family notification, despite facility policy requiring such actions. One resident, with diagnoses including non-Hodgkin lymphoma and osteoarthritis, experienced multiple falls over a short period. Progress notes showed that after these incidents, staff sometimes notified the family but failed to notify the physician, and in some cases, neither party was notified. Staff interviews revealed confusion about what constitutes a fall and when notifications should occur, with some staff believing that sliding from a bed or chair did not require physician notification if there were no injuries. Another resident, with high blood pressure and lung cancer, also experienced a fall that was not followed by documented notification of the physician or family. Interviews with nursing staff, the MDS Coordinator, the DON, and the Administrator confirmed inconsistent practices regarding post-fall notifications. Some staff stated that physician notification was not always performed, especially during night shifts or if there were no injuries, despite the expectation that both family and physician should be notified after any fall. The facility did not provide a specific policy regarding falls or physician notification, and the existing documentation policy did not substitute for required event reporting and notifications.