Failure to Notify Family of Resident Injury After Fall
Penalty
Summary
The facility failed to notify a resident's representative following an incident that resulted in injury. A male resident with multiple diagnoses, including type 2 diabetes with foot ulcer, atherosclerotic heart disease, congestive heart failure, and stage 3 chronic kidney disease, experienced a fall while attempting to transfer from his bed to a wheelchair without assistance, despite requiring a two-person assist and a Hoyer lift for transfers. The resident was later observed with swelling to his face and right arm, and was subsequently sent to the hospital after physician notification. Interviews with nursing staff revealed inconsistencies in the notification process. One nurse stated she notified the physician, hospice, and family members after the fall, while another nurse relied on previous charting that indicated family notification had occurred. However, the resident's family member reported not being informed of the fall until the resident was being sent to the hospital, and documentation did not clearly indicate whether a message was left or if follow-up attempts were made after an initial unsuccessful call. Record reviews showed that progress notes and incident reports documented that the physician, hospice, and family were notified, but there was no conclusive evidence that the family was actually reached or informed in a timely manner. The facility's policies required immediate notification of family and documentation of such notifications following incidents or changes in condition, but these procedures were not consistently followed in this case.