Failure to Notify Responsible Party of Resident Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's fall, as required by facility policy. The resident, who had diagnoses including type 2 diabetes mellitus and end stage renal disease, lost balance while returning to bed and was assisted to the floor by a CNA. The resident subsequently complained of pain in the sacrum-coccyx area. Documentation in the nursing progress notes indicated that the incident was to be followed up by the day shift nurse, but there was no evidence that the RP was informed of the fall prior to the resident's discharge home with the RP. During interviews and record reviews, the Director of Nursing confirmed that no follow-up call or notification to the RP was documented, and that the expectation was for the day shift nurse to ensure the RP was made aware of the fall. The facility's policy on falling incidents required notification of both the physician and the responsible party, but this was not carried out in this instance.