Failure to Notify Physician and Delay in Care After Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the physician after an unwitnessed fall with injury involving a resident who was severely cognitively impaired. The resident was found to have pain and abnormal rotation of the left foot following the fall, but the physician was not notified until over four hours later. Despite clear signs of pain and functional decline, including increased difficulty with transfers and the resident vocalizing pain, staff continued to transfer the resident multiple times without obtaining further physician orders or additional assessment. Throughout the following day, the resident's pain intensified, and he became increasingly unable to bear weight, requiring assistance from three staff members for transfers. Staff administered acetaminophen for pain, but the resident continued to exhibit severe pain, especially during movement. Although a femur x-ray was ordered and returned negative, a hip x-ray was not promptly obtained, and the resident was not transferred to the hospital until the physician was finally updated and gave the order. Interviews revealed that staff were instructed by the DON not to send the resident to the hospital and to withhold physician notification, despite ongoing severe pain and functional decline. The resident was eventually sent to the emergency room, where he was diagnosed with an acute displaced femoral neck fracture requiring surgical intervention. The facility's failure to promptly notify the physician, delay in obtaining appropriate diagnostic imaging, and continued transfers without proper orders resulted in actual harm to the resident. Facility policy required prompt physician notification and follow-up for falls with injury, which was not followed in this case.