Failure to Provide Timely and Appropriate Care After Resident Fall with Head Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, legal blindness, and dependence on staff for all activities of daily living experienced a fall resulting in a head injury, scalp laceration, hematoma, and a fractured cervical vertebra. The resident was found on the floor by a CNA, and the assigned LVN responded by applying pressure to the bleeding wound and then moving the resident from the floor to the bed using a mechanical lift before notifying medical personnel or emergency services. The LVN did not immediately call 911, instead prioritizing stopping the bleeding and transferring the resident, despite the presence of significant head trauma and altered vital signs. The LVN delayed contacting the physician and the DON, waiting approximately 30 minutes after the fall to notify the physician and about an hour to notify the DON, who then instructed the LVN to call 911. Emergency services were not summoned until over an hour after the incident, during which time the resident exhibited elevated blood pressure, a large hematoma, and was uncooperative with assessment. The LVN acknowledged in interviews that she was aware of the importance of not moving a resident with a suspected head or neck injury and that she should have called for assistance and emergency services immediately, but failed to do so at the time. The facility's care plan and fall prevention protocols required staff to assess for injuries and avoid moving residents with suspected head or neck trauma, as well as to notify emergency services promptly in the event of significant injury. Despite these protocols, the LVN moved the resident and delayed emergency notification, actions which were confirmed by documentation, staff interviews, and review of the resident's medical records. The resident was subsequently diagnosed at the hospital with multiple traumatic injuries, including a subarachnoid hemorrhage and cervical fracture.