Delayed Treatment After Fall and Failure to Discontinue Medication Order
Penalty
Summary
The facility failed to prevent a delay in treatment after a fall resulting in a fracture for one resident. After the resident, who had severe cognitive impairment, fell and complained of hip and knee pain, staff assessed her but did not immediately notify the physician or document timely communication regarding her pain and the fall. The resident was moved to bed despite her complaints of pain, and there was a lack of clear documentation about when the physician was notified. An x-ray was ordered later, revealing an acute femur fracture, but the results were not promptly acted upon, and the resident was not sent to the hospital until the following day. Facility policy required that suspected bone or joint injuries not be moved until seen by a physician or transported, and that abnormal diagnostic results be promptly communicated to the physician, which was not followed in this case. In a separate incident, the facility failed to ensure a treatment order for a topical cream was discontinued or clarified after 60 days for another resident. The order for Ammonium Lactate Cream was written without a specific stop date and remained active beyond the intended duration. The pharmacy recommended discontinuation after 60 days, but there was no documentation that the order was discontinued or clarified. The DON indicated the pharmacy recommendation should have been addressed by nursing staff, and the pharmacist should have included a stop date when the order was initiated. Both deficiencies were supported by interviews and record reviews, which revealed lapses in communication, documentation, and adherence to facility policies regarding physician notification, post-fall assessment, and medication order management. These failures resulted in delays in appropriate treatment and care according to physician orders and resident needs.