Failure to Complete Weekly Skin Assessments and Timely Diagnostic Testing After Fall
Penalty
Summary
The facility failed to provide weekly skin assessments as ordered by the physician for one resident and did not address physician orders for diagnostic testing in a timely manner for another resident following an unwitnessed fall. For the first resident, there were multiple periods where weekly skin assessments were not completed or documented, despite active physician orders requiring these checks. Nursing progress notes and charted assessments confirmed gaps in the completion of these assessments, and staff interviews corroborated that the process at the time relied on a single nurse, which resulted in missed assessments. For the second resident, after an unwitnessed fall, the facility did not ensure that ordered diagnostic imaging was completed promptly. The resident, who had a history of falls, multiple comorbidities including MS, diabetes, and chronic kidney disease, and was dependent for mobility, experienced a fall resulting in pain and a skin tear. Although a mobile x-ray was ordered, there was a delay of several days before the imaging was completed and the results were received, during which time the resident continued to experience pain and developed altered mental status. Documentation showed that staff followed up with the imaging company, but the x-ray was not performed until days after the initial order, and the resident was ultimately found to have a femoral fracture and was transferred to the hospital. Interviews with staff and the resident revealed that the resident was unable to reach the call light after the fall and that family notification was delayed, with the resident's son only learning of the injury through a relative. The DON confirmed the delay in imaging and stated that the resident's pain was not reported to be higher than baseline, which influenced the decision not to send the resident out for more urgent imaging. Facility policies reviewed indicated requirements for timely assessment and intervention following accidents and for regular skin assessments, which were not met in these cases.