HospitalInspections.org

Based on interview and review of the facility's Incident Management policy, it was determined the facility failed to make appropriate notifications to the designated Next of Kin after Patient #1 was emergently sent to a local hospital for evaluation following an observed fall that resulted in a fractured pelvis and fractured left femur (thigh bone).

The findings include:

Review of the facility policy #ML 10010 titled "Incident Management", revised 02/27/14, revealed the patient's guardian would be promptly notified in the event of a Class III incident which was defined as being critical in nature and presented an immediate threat to the person's welfare and safety.

Review of Patient #1's clinical record revealed the facility admitted him/her on 09/19/14 with diagnoses which included Dementia with Behaviors, Recent Urinary Tract Infection and history of a prior Pelvic Fracture. Review of the Consultant Report, dated 10/11/14, revealed Patient #1 sustained a fall on 10/11/14 and was referred to a local hospital for "medical necessity". Review of the Face Sheet, completed by the facility upon admission, revealed Patient #1 had a documented Next of Kin, who was also Power of Attorney, with contact information included.

Interview with Mental Health Associate #1, on 10/17/14 at 2:11 PM, revealed a patient's representative should be notified in the event of a fall.

Interview with Registered Nurse #1, on 10/17/14 at 2:25 PM, revealed a patient's Guardian should be notified if the patient had a fall.

Interview with Patient #1's daughter (listed as Next of Kin on the Face Sheet), on 10/17/14 at 3:12 PM, revealed the facility did not notify her of Patient #1's fall and subsequent transfer to the emergency room on 10/11/14. Continued interview revealed she was notified by the hospital on the morning of 10/12/14 and informed Patient #1 had been admitted to the hospital and required surgery to repair a fracture sustained in a fall the previous day.

Interview with the Nurse Manager, on 10/14/18 at 3:32 PM, revealed if notification of a patient's change in condition was required, the designated Next of Kin could be notified if there was not an assigned legal Guardian.