Failure to Notify Physician of Resident Pain and Injury After Altercation
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a resident's complaint of pain following a resident-to-resident altercation that resulted in a fall. The resident, an elderly male with severe cognitive impairment, Parkinson's disease, dementia, and other comorbidities, was pushed by another resident, causing him to fall and sustain an abrasion to his right elbow. Initial assessments documented that the resident denied pain and did not report hitting his head, and the incident was reported to the family, administration, and local authorities. However, subsequent documentation showed that the resident later complained of tenderness to the left buttock, for which pain medication was administered by nursing staff, but the physician was not notified at that time. The resident was later taken to a physician appointment by a family member, where he reported pain in the sacral area. The physician ordered an x-ray, which revealed a suspected non-displaced fracture of the coccyx. The facility did not become aware of the x-ray results until the spouse reported them several days later. Additionally, emergency department records faxed to the facility also documented the coccyx fracture, but these records were not reviewed or acted upon by facility staff in a timely manner. Multiple staff members, including the Assistant Director of Nursing and a Registered Nurse, stated they were unaware of the fracture documented in the hospital records. The facility's policy required timely communication of medical care problems to the attending physician and family. Despite this, the physician and nurse practitioner were not informed of the resident's pain complaints or the x-ray findings until after the family reported them. The nurse practitioner indicated that, had she been notified, she could have ordered the x-ray and adjusted pain management sooner. The lack of timely physician notification and review of hospital records led to a delay in appropriate assessment and treatment for the resident's injury.