Failure to Notify Physician and Health Care Agent After Resident Fall
Penalty
Summary
Staff failed to promptly notify a resident’s physician and Health Care Agent (HCA) after the resident experienced a significant change in status related to a fall. The resident had been admitted with diagnoses including status post fall with a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use, and had an invoked Health Care Proxy. Facility policy required prompt notification of the resident, physician, and resident representative of changes in medical or mental condition, including accidents or incidents. On the morning in question, one nurse (Nurse #2) found the resident on the floor next to the bed and obtained the assigned nurse (Nurse #1) to assist. After assessing the resident for injury and returning the resident to bed, neither nurse completed the required fall documentation or made the required notifications to the physician or HCA at that time. Nurse #1 stated that at the end of her shift she had not completed any documentation related to the fall and assumed Nurse #2 would do so, and confirmed she did not notify the physician or HCA. Nurse #2 stated she assumed Nurse #1 would complete the documentation and notifications and did not verify that this occurred, and did not report the fall to anyone until the following morning during nurse-to-nurse report; she later entered a late note about the incident. Review of the medical record showed no documentation that the unwitnessed fall was reported to the physician until several days later. The Staff Development Coordinator and DON both reported they were unaware of the fall until the DON began an investigation into a bruise of unknown origin near the resident’s right eye, which had been identified by the resident’s HCA during a visit. A family member reported discovering the bruise during a visit and being told by a nurse that the resident had likely fallen the previous day, and also reported that no one from the facility had notified her of the fall.
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