Failure to Promptly Notify Family and NP After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s family and nurse practitioner after two separate falls. The resident had dementia, a prior pubic fracture, osteoarthritis, a right shoulder bone density disorder, and spinal stenosis. On one occasion, a nurse documented that the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a small dresser, resulting in a small bruise on the left side of the forehead. The nurse later stated she did not notify the resident’s family of this fall until the following day, despite recognizing that the resident must have hit her head due to the mark and bruise. The resident’s daughter/POA confirmed she was not notified of this fall until the next day and stated she expected to be called right away. On another occasion, a nurse documented that during routine rounds around 12:30 a.m., the resident was found lying supine on the floor in her room wearing non-skid socks and gesturing to staff to get her up. Less than 24 hours after this fall, the resident was diagnosed with a fractured left hip and left elbow. The LPN who authored the note stated she did not notify the family or the nurse practitioner after this fall. The resident’s daughter/POA reported she was not informed of this second fall until two days later by the DON. The DON stated that staff are expected to notify the family and provider after a resident falls so they can be aware of changes and make informed decisions, and the nurse practitioner stated she had not been notified of the fall and would have seen the resident if she had known. The facility’s Fall Prevention Program policy, reviewed 9/1/24, requires that after any resident fall, staff assess the resident, complete a post-fall assessment and incident report, notify the physician and family, and document all assessments and actions, which did not occur as required in these instances.
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