Failure to Notify Physician After Resident-to-Resident Grabbing Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a change in the resident’s condition after an incident with another resident. One resident with hemiplegia and hemiparesis following a cerebral infarction, who was mildly cognitively impaired and dependent on staff for transfers and walking, reported being scared when another resident grabbed the resident’s left arm in the hallway. The resident’s admission and assessment records showed the resident had capacity to understand and make decisions, and required substantial to maximal assistance with multiple activities of daily living. The other resident involved had diagnoses including metabolic encephalopathy, psychosis, and schizophrenia, and was documented as not having capacity to understand and make decisions, with severe cognitive impairment and substantial to maximal assistance needs. On the date of the incident, this resident was documented in progress notes and an SBAR as being agitated, yelling out, throwing objects, hitting their head against the wall, and grabbing other residents, and was subsequently sent to an acute hospital for further evaluation. Staff interviews confirmed that this resident grabbed the first resident’s arm in the hallway, which scared the first resident, and that the Social Services Director witnessed the incident while nursing staff checked on the affected resident. Record review and staff interviews with the Social Services Director, an LVN, and the DON confirmed that there were no progress notes or SBAR completed for the affected resident related to the incident, and that the resident’s physician was not notified that the resident had been grabbed, was scared, and was observed shaking and tearing afterward. The Social Services Director and LVN both stated that the physician should be notified whenever a resident has a change of condition, and the DON acknowledged that the physician was not made aware of the incident or the resident’s reaction. The facility’s written policy on Notification of Changes required informing and consulting with the resident’s physician when there is an accident with potential to require physician intervention or a significant change in the resident’s physical, mental, or psychosocial condition, which did not occur in this case.
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