Failure to Assess and Monitor After Unwitnessed Fall Resulting in Delayed Diagnosis of Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls did not receive appropriate assessment and care following an unwitnessed fall in the facility's dining room. The resident, who had diagnoses including dementia, Alzheimer's disease, lack of coordination, and muscle weakness, was found on the floor after a fall. Staff failed to perform a thorough assessment at the scene, including range of motion (ROM) checks, and did not initiate neurological checks as required by facility policy for unwitnessed falls. Documentation was incomplete, with no clear record of ROM assessment or neuro checks, and the incident was not fully detailed in the progress notes. Following the fall, the resident exhibited signs of pain and changes in behavior, such as vocalizing distress and refusing to move her leg during care. Despite these indications, there was a delay in recognizing the severity of her injury. Pain assessments were inconsistently documented, and staff responses varied, with some staff noting pain and others documenting none. The resident remained in bed and was not mobilized, but it was not until the following day that an x-ray was ordered, which revealed a right hip fracture requiring surgical intervention. Interviews with staff revealed confusion and inconsistency regarding the assessment process for unwitnessed falls, including when to perform neuro checks and how to document assessments. The facility's policies required immediate neuro checks and comprehensive assessments for unwitnessed falls, but these were not followed. The lack of timely and thorough assessment, documentation, and follow-up led to a delay in diagnosis and treatment of the resident's hip fracture.