Failure to Immediately Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's responsible party following an accident/fall, as required by facility policy. According to the record review, a resident with severe cognitive impairment and a diagnosis of dementia experienced a fall at 4:35 a.m., resulting in a significant hematoma and pain. The incident note documented that the physician was notified and x-rays were ordered, and it was indicated that the resident's power of attorney (POA) had been notified. However, interviews revealed that the family was not informed of the fall until several hours later, between 7:00 a.m. and 8:00 a.m. Staff interviews confirmed that the nurse on duty did not notify the resident's family immediately after the fall, instead waiting until later in the morning. The RN stated there was no specific time frame for notification other than before the end of the shift, while the DON clarified that immediate notification was required. The RN care coordinator also acknowledged that the responsible party should have been notified after the resident was assessed and the physician was contacted, but could not explain the delay. The facility's policy, dated May 2017, explicitly required immediate notification of the resident's representative following any accident or incident resulting in injury.