Failure to Complete SBAR and Monitor Resident After Hip Dislocation
Penalty
Summary
The facility failed to follow its policy and procedure for managing a change in condition for one of three sampled residents who experienced a dislocated hip. Specifically, staff did not complete an SBAR (Situation, Background, Appearance, Review and Notify) form to notify the physician of the change in condition, nor did they monitor the resident for changes after the dislocation was identified. Progress notes indicated that the dislocation was discovered via X-ray, and the physician was notified, but there was no documentation of detailed observations or use of the SBAR communication tool as required by facility policy. Additionally, the resident, who had a history of spontaneous hip dislocations, continued to experience pain and was eventually sent to the emergency room for further evaluation and treatment at the request of the family. The Director of Nursing confirmed during interview and record review that there was no completed SBAR or evidence of monitoring for the resident following the dislocation. The facility's policy required nurses to gather and document pertinent information using the SBAR form and to record changes in the resident's condition in the medical record, which was not done in this case.