Failure to Provide Timely Assessment and Notification After Resident Fall
Penalty
Summary
A resident with a history of dementia, osteoarthritis, and a previous left hip fracture experienced an unwitnessed fall in her room. The resident was found on the floor by a nurse aide, who then sought assistance from a nurse. The nurse assessed the resident, who denied pain and injury at the time, and assisted her back to bed using a mechanical lift. However, the incident was not reported to the assigned nurse, and no fall incident report was completed immediately. The responsible party and physician were not notified of the fall on the day it occurred. Due to the lack of communication, the assigned nurses on subsequent shifts were unaware of the fall and did not monitor or document the resident's condition in relation to the incident. Later that night, the resident began to complain of pain, which was initially attributed to a previous injury. Swelling and abnormal coloration of the right leg were observed, but the physician and responsible party were still not notified promptly. The delay in recognizing the significance of the symptoms and the lack of ongoing assessment contributed to a delay in appropriate treatment. The incident report and post-fall investigation were not completed until the following day, after the nursing supervisor became aware of the situation. The resident was eventually evaluated and diagnosed with a right hip and femur fracture, but only after a significant delay in assessment and intervention. The failure to provide thorough and ongoing assessments, timely communication, and prompt notification to the responsible party and physician resulted in a delay in treatment for the resident following the fall.