Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident’s change in condition following a fall and subsequent transfer to the emergency room. The resident had diagnoses including vascular dementia, stridor, cerebral infarction, and dysphagia, and an admission MDS with a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making. The resident’s face sheet identified a family member as the responsible party and primary emergency contact. Nursing documentation showed that in the early morning hours the resident was found on the floor in his room with a small bruise to the orbital area, and later that same day the resident was sent to the ER. During clinical record review, the surveyor was unable to locate any documentation that the responsible party had been notified of either the fall or the ER transfer. When requested during an end-of-day meeting, facility leadership could not provide evidence of such notification, despite a facility policy titled “Significant Change of Condition” stating that the responsible party will be notified of a change of condition. The DON later confirmed they were unable to find any notification to the responsible party regarding the fall and acknowledged that the responsible party should have been notified when the resident fell and was stabilized.
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