Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and the responsible party of a resident's change in condition following an unwitnessed fall. The resident, who had a history of dementia, osteoarthritis, and a previous hip fracture, experienced a fall in her room. Although a physical assessment was completed at the time of the incident and no injury or pain was initially reported, the event was not communicated to the oncoming nurse, resulting in a lack of documentation and monitoring for changes related to the fall during the subsequent shift. During the night, the resident began to complain of pain and exhibited swelling and discoloration in her right leg, which was not typical for her. The assigned nurse provided routine pain medication but did not notify the physician or the responsible party of these new symptoms, instead reporting the change in condition only to the oncoming nurse at shift change. It was not until the following morning that the nurse practitioner was notified, who then ordered a stat x-ray and informed the responsible party. The x-ray revealed an intertrochanteric fracture of the right femur. Interviews with staff and the responsible party confirmed that neither the physician nor the responsible party was notified promptly when the resident first reported pain and swelling. The responsible party stated she would have wanted the resident sent to the hospital for evaluation had she been notified at the time. The medical director also indicated that provider notification should have occurred when pain and swelling were first observed.