Failure to Timely Notify Resident Representative of Incident
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative in a timely manner following an incident involving the resident. The resident, who had diagnoses including dementia, legal blindness, and cellulitis, and was assessed as having severely impaired cognition, was involved in an aggressive altercation with staff that resulted in the need for psychiatric evaluation. The incident was documented in the facility's records, but the notification to the family was not completed promptly. The family only became aware of the event when they visited the resident, who was visibly upset, and learned about the incident directly from the resident and staff present at the time. The facility's policy required immediate notification of the resident's representative in the event of an accident or incident. However, the incident report did not include a date or time for family notification, and staff interviews revealed uncertainty about whether and when the family was contacted. The family expressed concern during a subsequent meeting, stating they were not informed about the incident until their visit. The lack of timely communication was confirmed through interviews with staff and review of grievance documentation.