Failure to Notify Resident Representative of Change in Condition After Wheelchair Incident
Penalty
Summary
The facility failed to notify a resident’s representative of a change in condition after the resident was observed sliding from a wheelchair to the floor. Facility policy dated 12/2024 required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative and reported to the attending physician, and that staff be educated to identify and report such changes. Resident #1, who had diagnoses including constipation, chronic pain syndrome, history of falling, and moderately impaired cognition per the 11/22/2025 MDS, was seen on 12/06/2025 at 5:00 PM by Occupational Therapist Assistant #1 sliding from the wheelchair to the floor. Record review showed no documented evidence that Resident #1’s representative was notified of this event. During interview, Registered Nurse Supervisor #2 stated that upon body assessment there were no visible injury, trauma, or skin changes, and acknowledged that neither the medical doctor nor the resident’s representative was informed of the incident. In a separate interview, the Director of Nursing stated that Registered Nurse Supervisor #2 was required to notify the medical doctor and the resident’s family representative when the resident slid from the wheelchair to the floor. This failure to notify the representative of a change in condition was cited under 10 NYCRR 415.3(e)(2)(ii)(b).
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