Failure to Notify Resident Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident representative for a resident who experienced a fall. The resident, who had multiple diagnoses including Parkinsonism, hypertensive heart disease, repeated falls, and cognitive impairment, was found sitting on the floor in her bedroom after sliding out of bed. The nurse documented the incident and notified the physician and unit managers, but there was no documentation that the resident's Medical Power of Attorney (MPOA) was informed of the fall, as required by facility policy. A family member later raised a concern about not being notified of the fall, which was documented in the facility's Concern Log. The nurse involved stated that she did not notify the emergency contact or MPOA because the resident was listed as her own responsible party on the face sheet. However, the Director of Nursing confirmed that the nurse should have contacted the MPOA as indicated in the resident's record. The facility's policy requires notification of resident representatives for changes in condition, including accidents and incidents.