Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition following a fall. A resident admitted for a respite stay with a history of falling and dementia was on a locked memory care unit when a staff member opened a door, startling the resident, who then fell to the floor onto the right side. The resident was non-verbal but moaned in pain when the right leg was touched, although some range of motion remained. Facility documentation shows that hospice was notified and a hospice nurse assessed the resident later that evening, noting no complaints of pain, the ability to move the leg without complaint, and no new orders. The hospice nurse indicated they would follow up and inform the resident’s family. The facility’s fall investigation and review of the electronic medical record revealed no documentation that the resident’s responsible party was notified of the fall on the day it occurred. The investigation noted that the hospice nurse stated they would notify the family, and there was no follow-up by facility staff to ensure that this notification actually occurred. Interviews with the Administrator, CMT, RN, LPN, and DON confirmed that nurses were responsible for notifying a resident’s responsible party immediately after a change in condition and that the facility remained responsible for notification even if a hospice nurse said they would notify the family. Staff and leadership acknowledged that the resident’s family was not notified by the facility on the day of the fall and that the family was notified later than expected under facility policy and practice.
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