Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party was immediately notified following a significant change in condition related to a fall. According to the incident report and nursing notes dated 01/11/2026, the resident experienced an unwitnessed fall that resulted in active bleeding and a large hematoma on the forehead. The LPN obtained physician orders to send the resident to the emergency room for evaluation. Documentation on the incident report and in the nurse’s note showed that the LPN attempted twice, unsuccessfully, to contact the resident’s responsible party/daughter at the time of the incident and transfer. In a subsequent telephone interview, the resident’s responsible party reported that she was not notified by the facility about the fall or the emergency room transfer and instead learned of the event from hospital staff on the same date. During an interview, the LPN confirmed that the date and time documented as responsible party notification on the incident report reflected only the attempted, but unsuccessful, calls. The LPN acknowledged making two unsuccessful attempts to notify the responsible party. The DON later confirmed that the LPN should have notified the resident’s responsible party of the fall and the emergency room transfer, establishing that required immediate notification did not occur.
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