Delayed Evaluation and Treatment of Foot Injury
Penalty
Summary
A resident with a history of orthostatic hypotension and syncope experienced a new onset of right foot pain after being assisted with a transfer. The pain was severe, with swelling and a high pain score reported. Nursing staff notified a nurse practitioner (NP) and a STAT X-ray was ordered, which initially showed no fracture. Despite ongoing complaints of pain, swelling, and the resident's inability to participate in physical and occupational therapy, there was no documented thorough evaluation of the right foot by a medical provider in the days following the injury. Progress notes indicated that the resident continued to experience significant pain and swelling, and therapy staff repeatedly documented the resident's inability to participate in therapy due to pain. Although the resident was seen by a PM&R physician and the NP was notified, documentation did not reflect a focused assessment of the injured area or address the acute pain and functional decline. The resident's pain was sometimes attributed to chronic neuropathy, and the acute injury was not specifically evaluated. It was not until six days after the initial injury that the attending physician documented a comprehensive assessment of the right ankle, noting significant swelling, bruising, and the resident's inability to bear weight. The resident was then placed on non-weightbearing status and referred for further evaluation. Subsequent imaging, including a CT scan, revealed a moderately comminuted avulsion fracture of the calcaneus with multiple displaced bony fragments. The delay in thorough evaluation and diagnosis resulted in prolonged pain and limited participation in rehabilitation. Interviews with facility staff, including the DON and PM&R physician, confirmed gaps in documentation and assessment, with uncertainty about which NP was contacted and a lack of clear documentation regarding the evaluation of the resident's acute injury.