Failure to Notify PCP of Resident's Ongoing Change in Condition After Fall
Penalty
Summary
The facility failed to ensure timely identification and communication of a resident's change in condition to the Primary Care Provider (PCP) as required by facility policy. After a resident experienced a fall, the PCP was initially notified of the incident. However, over the following days, the resident continued to report ongoing pain in the right hip, groin, thigh, pelvis, and right torso. Despite these persistent complaints and changes in the resident's condition, there was no documented evidence that the PCP was updated about the resident's continued pain or change in status until the resident was seen by the PCP several days later and diagnosed with a right 11th rib fracture. The resident involved had a complex medical history, including anemia, end stage renal disease, dementia, malnutrition, anxiety, depression, and chronic obstructive pulmonary disease, with severely impaired cognition and behavioral symptoms. The failure to notify the PCP of the resident's ongoing pain and refusal of care following the fall was confirmed by the Director of Nursing, who acknowledged that staff did not provide timely updates to the PCP regarding the resident's condition between the initial fall notification and the subsequent diagnosis of a rib fracture.