Failure to Notify Correct Family Representative After Resident Injury
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's physical condition. Specifically, after a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and altered mental status, experienced a fall resulting in injuries to the face, eyes, and head, the facility did not promptly inform the correct family representative. The initial attempt to notify was made by calling the first contact listed on the resident's face sheet, but this was not the correct representative, and only a voicemail was left. There was no documented evidence of follow-up attempts or efforts to contact other listed representatives when the initial call was not returned. Interviews with staff revealed that the wrong contact was repeatedly called, and the correct representative was not informed of the incident until they visited the facility over a month later. The care plan for the resident included interventions to ensure safety and communication, but these were not effectively implemented regarding family notification. The facility's own policy required notification of family or significant others in the event of an accident or incident, but this was not followed, as evidenced by the lack of timely and appropriate communication with the designated representative.