Failure to Notify Physician and Family of Resident Fall and Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative and physician of a significant change in the resident's condition following a fall. The resident, an elderly male with severe cognitive impairment, dementia, diabetes, hypertension, end stage renal disease, lack of coordination, and neuropathy, was found on the floor after midnight by an LVN. The LVN did not report the incident as a fall, did not notify the responsible party (RP) or physician, and did not complete the required documentation or incident report at that time. The LVN assumed the resident had simply slipped out of bed and did not consider it a fall since the resident denied falling and was not complaining of pain at that moment. Later in the day, the resident was noted to be non-compliant with therapy and was assessed for pain and a bulging area on the right side. The physician was contacted in the afternoon regarding the resident's pain, and an x-ray was ordered, which later revealed a fracture. The RP was notified only about the new orders and the need for an x-ray, but was not informed about the fall itself. The physician was also not informed that the resident had fallen, only that he was experiencing pain. The RP only learned about the fall incident much later, after another family member visited the facility. Interviews with facility leadership, including the Administrator and DON, confirmed that their expectation was for staff to report all falls, complete assessments, document findings, and notify the appropriate parties, including the physician and family. The LVN involved admitted to not notifying the RP or physician and not recognizing the incident as a fall. The facility's policy requires immediate notification of accidents resulting in injury or significant changes in condition, but this protocol was not followed in this case.