Delay in Emergency Response for Resident with Altered Mental Status After Fall
Penalty
Summary
The facility failed to follow its change in condition policy by not promptly calling advanced life support services (911) for a resident who was found with altered mental status and was verbally unresponsive. The resident, who had a history of atrial fibrillation, was on anticoagulant therapy, and was at high risk for falls, experienced an unwitnessed fall. Despite being found on the floor by a CNA and assessed by a nurse, the resident was not immediately sent to the hospital, even though facility staff acknowledged that residents on anticoagulants with unwitnessed falls should be evaluated for possible brain bleeds. The following morning, the resident was found unresponsive and not behaving as usual, with staff noting a significant change from his baseline mental status. The nurse notified the physician, who ordered a transfer to the hospital. However, instead of calling 911 as required by the facility's policy for medical emergencies involving unstable vital signs or unresponsiveness, staff called a basic life support (BLS) ambulance. Upon arrival, the BLS crew determined the resident's condition was critical and required advanced life support, prompting them to call 911 for an upgrade in care. Emergency medical services found the resident with decerebrate posturing, irregular bradypnea, and a Glasgow Coma Scale of 7, indicating severe neurological compromise. The resident was intubated and transferred to the ICU for ventilator management. Hospital records confirmed the resident had suffered rib fractures and was diagnosed with COVID and pneumonia. The delay in calling 911 and failure to follow the facility's change in condition policy resulted in a significant delay in appropriate emergency intervention for the resident.