Failure to Notify Resident Representative After Fall With Injury and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a fall with injury and subsequent transfer to the hospital, as required by facility policy. The facility had written policies titled “Assessing Falls and Their Causes” and “Change in a Resident’s Condition or Status,” which directed staff to notify the resident’s family or representative when a resident fell, sustained an injury, experienced a significant change in condition, or required transfer to a hospital or treatment center. Despite these policies, the resident’s Durable Power of Attorney (DPOA), listed as the emergency contact and responsible party in the admission record, was not notified when the resident experienced a fall and was sent to the hospital. The resident involved had moderate cognitive impairment and diagnoses including Huntington’s Disease and a cognitive communication deficit, as documented on a Quarterly MDS. On the night of the incident, the resident’s roommate alerted the nurse that the resident had fallen out of bed. When the nurse entered the room, the resident was found on the floor with blood on the mouth and a red mark on the back of the head. The nurse contacted an ambulance, the DON, and the resident’s physician, and the resident was transported to the hospital, where the resident received sutures for a laceration sustained from the fall. During interviews, the LPN who was the charge nurse at the time acknowledged being aware that the resident had a responsible party and was not considered his or her own decision-maker, and also acknowledged knowing that the DPOA should have been notified of the fall and hospital transfer. The LPN stated that the DPOA was not notified and that this was due to forgetting to make the call. The DPOA later learned of the fall and injuries indirectly from a family friend who worked at the facility approximately eight hours after the incident, rather than from the responsible nursing staff. The DPOA reported not being informed by the charge nurse, expressed that they would have wanted to be present at the hospital, and described the resident’s injuries, including a laceration requiring sutures, facial bruising and swelling, and leg injuries.
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