Failure to Notify Physician After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to notify the attending physician following a significant change in condition for a resident who experienced a fall with a head injury. According to the facility's policy, staff are required to promptly notify the resident, their attending physician, and the resident's representative of any changes in medical or mental condition, including accidents or incidents. In this case, a cognitively impaired resident, who required extensive assistance with bathing and was being assisted by a hospice aide, fell in the shower room, resulting in a raised, purple area above the right eye. The DON was notified and responded to the incident, initiated neurological checks, and assessed the resident, but did not notify the attending physician as required by policy. Interviews revealed that the DON relied on the hospice nurse to notify the family and hospice nurse practitioner, and believed that hospice staff would determine the next steps for a resident on hospice care. However, both the administrator and corporate nurse confirmed that facility staff are responsible for notifying the attending physician in the event of a fall, especially one involving a head injury. The care plan for the resident did not document fall risk assessment or interventions for falls, and the nurse's notes lacked documentation of physician notification after the incident.