Failure to Notify Physician and Family of Resident Incident and Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative and physician following a significant change in the resident's physical status. Specifically, a nurse entered the resident's room and accidentally hit the resident with the door. The nurse did not complete an incident report, document assessments, or initiate required ongoing monitoring for delayed injury. Additionally, the nurse did not notify the resident's responsible representative or physician about the incident or about the resident's broken dentures, which were discovered during the resident's stay. The resident involved was an elderly female with Alzheimer's disease, admitted for a short respite stay and was on anticoagulant medication, increasing her risk for bruising and injury. The resident was ambulatory, had wandering behaviors, and required a secured unit. During her stay, she was noted to have removed her upper dentures frequently, and staff later discovered the dentures were broken. The nurse reported the broken dentures to the Assistant Director of Nursing (ADON) but did not notify the family or physician at the time. When the resident's family arrived to pick her up, they observed bruises on her arms and forehead and noticed the broken dentures. They reported not being informed about the incident with the door, the lab work, or the broken dentures. Interviews with facility staff confirmed that the nurse did not document or report the incident or the broken dentures as required by facility policy, which mandates immediate notification and documentation of such events.