Failure to Provide Timely Assessment and Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with a history of falls and previous fractures. The resident, who was cognitively intact and ambulated independently with a walker, experienced a fall while walking to the bathroom. After the fall, the resident was found on the floor, complaining of significant pain (8 out of 10) in her left shoulder and left hip, and requested to be sent to the hospital. The LPN on-site notified the DON, who was the RN on-call, but no RN was present in the facility to conduct a hands-on assessment at the time of the incident. The resident was assisted into a wheelchair by the LPN and a CNA despite her complaints of severe pain and refusal to allow removal of her clothing for a skin evaluation. Documentation revealed that the DON's assessment was based on the LPN's report rather than a direct evaluation, and the nursing note was not entered into the electronic medical record until several hours later. There was no evidence that the physician was notified of the resident's acute pain and refusal of a skin evaluation prior to moving her, nor was there documentation of physician orders for X-rays before the resident's representative insisted on hospital transfer. The resident was ultimately transported to the hospital over an hour after her initial request, where she was diagnosed with a dislocated and fractured left shoulder and a fractured left hip, both requiring surgical intervention. Interviews with staff and the resident's representative confirmed inconsistencies in the facility's response, including delays in contacting EMS and obtaining physician orders, as well as discrepancies in staff accounts regarding the resident's pain and requests for hospital transfer. The facility's policies required a physical assessment by a licensed nurse after a fall and immediate attention for significant changes in condition, but these procedures were not followed. The lack of timely and appropriate assessment, documentation, and response to the resident's acute pain and request for hospital evaluation constituted a failure to provide care in accordance with professional standards.