Failure to Notify NOK and Physician of Resident Fall
Penalty
Summary
The facility failed to notify the next of kin (NOK) and physician of a resident fall, as required by its own Event Reporting Policy. The policy states that all events, including falls, must be reported to the resident's physician and family or power of attorney. In this incident, a resident with late onset Alzheimer's dementia, short term memory loss, and a history of right femur fracture surgery was found sitting on the floor next to their bed by a CNA. Video evidence confirmed the resident was on the floor, and staff questioned the resident about hitting their head or falling out of bed. Despite this, there was no documentation in the resident's progress notes regarding the fall, nor any record that the physician or NOK were notified. Interviews with the involved CNAs revealed that they did not consider the event a fall and therefore did not report it. However, the DON and Executive Director confirmed that such an event should be classified and reported as a fall according to facility policy, and that appropriate notifications should have been made.