Failure to Follow Change-in-Condition Notification Policy After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for immediate notification of a resident’s change in condition after an unwitnessed fall. The resident was admitted with multiple significant diagnoses, including COPD, atrial fibrillation, cirrhosis, bone disorders, prior fractures, and was on an anticoagulant. An MDS showed the resident was cognitively intact and required staff assistance for toileting and transfers. The resident reported that during the night she activated her call light because her incontinence brief was wet; a CNA responded, was told the resident needed to be changed, and stated she would return. The resident stated she could not wait, attempted to transfer herself to her wheelchair to go to the bathroom, and fell forward. She reported using her cell phone to call the facility to report the fall, sustaining a skin tear on her left arm, and experiencing back pain throughout the night. The next morning, a pulmonary nurse assessed the resident around 8:30 AM and found her confused, with mentation documented as alert and oriented times one, a quarter-sized hematoma on the right forehead, and a skin tear on the left upper extremity. The resident told the nurse she had fallen the previous night and had back pain, and the nurse noted the resident was on apixaban and arranged for transfer via EMS. The progress note documented notification of the Administrator and DON and that the nurse practitioner was notified, but the DON later stated that facility policy requires the nurse to immediately notify the primary physician, make at least two attempts, and if unsuccessful, escalate to the medical director, with all attempts documented. The DON reported that the nurse said she left a message with the resident’s doctor, but there was no documentation of further attempts or actual physician contact, nor documentation of medical director notification. The facility also lacked documentation that the resident’s representative was immediately notified of the fall, and the fall event assessment listed the representative as notified at 5:00 AM without clear correlation to the time of the fall, demonstrating noncompliance with the facility’s notification policy.
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