Failure to Timely Notify Physician and Representative After Unresponsive Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and resident representative when a resident was found unresponsive on the floor with a head laceration. The resident had multiple diagnoses, including dementia, COPD, type 2 diabetes with neuropathy, bladder cancer, coronary artery disease, major depression with psychotic symptoms, anxiety disorder, osteoarthritis, history of TIA, and hypertension, and had been assessed with severe cognitive impairment but independent ambulation and transfer. The care plan for fall risk required that if the resident fell or was found on the floor, staff were to assess for injury and notify the MD and responsible party. On the morning of the incident, a CNA informed an LPN that the resident had an unwitnessed fall and was lying on the bathroom floor. The LPN found the resident on the bathroom floor with his head under the sink, diaphoretic, sweaty, clammy, with a laceration to the top of the head, and unable to perform ROM due to lack of consciousness. Neuro checks were initiated. Despite the resident’s loss of consciousness and head injury, the physician was notified only by fax at 9:00 a.m., and there was no immediate telephone contact. The physician’s faxed response to send the resident to the emergency room was not received until 12:45 p.m., approximately four hours and 45 minutes after the fall, by which time the resident had already been transported to the hospital. The resident’s representative (POA) was not notified of the fall until 10:45 a.m., about two hours and 45 minutes after the incident, and was later notified again regarding the transfer to the emergency room. The facility’s policy required immediate notification of the resident, physician, and resident representative when there is an accident, significant change in status, or symptoms such as loss of consciousness. In an interview, the DON confirmed that the physician was not contacted immediately and that a telephone call should have been made instead of relying on a fax, and also confirmed the delay in notifying the resident representative.
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