Failure to Assess and Monitor Resident After Return with Fractures
Penalty
Summary
A resident with a history of peripheral vascular disease, traumatic brain injury, and cognitive deficit sustained a spiral fracture of the right tibia and multiple fractured ribs following a facility incident. Upon returning from the emergency room, the resident was assisted to bed with an immobilizer on the right lower leg and complained of pain. Documentation shows that while the immobilizer was noted to be in place, there was no thorough assessment of the right leg or the resident's overall status at that time. No nursing assessments were completed the following day, and subsequent notes focused on pain management without detailed evaluation of the injuries. Further documentation revealed that the resident experienced pain and distress, with pain medication being adjusted accordingly. Edema of the lower extremities was later observed, but again, no comprehensive assessment of the fractured leg or ribs was documented. The Director of Nursing confirmed that follow-up assessments were expected but not found in the records. The facility's acute condition change policy required monitoring and documentation of the resident's progress and response to treatment, which was not consistently followed in this case.