Delay in Fracture Management Following Resident Fall
Penalty
Summary
A resident with a history of metabolic encephalopathy, bipolar disorder, and dementia, and with moderate cognitive impairment, experienced a fall while attempting to change position in bed. Initially, no injury was noted, but the following day, swelling and discoloration were observed in the resident's right hand and wrist. A STAT X-ray was ordered and performed, revealing an acute fracture at the base of the fourth finger. Despite this finding, no immediate interventions to support or stabilize the fractured finger were implemented. The physician assistant (PA) reviewed the X-ray results but did not communicate the fracture to the nursing staff or discuss treatment options with the resident. The director of nursing (DON) and other staff were unaware of the fracture until several days later, as the PA had cleared the result in the electronic dashboard without notification. There was no documentation of any refusal by the resident to be sent to the hospital, and the PA later confirmed that the resident had not refused transfer and that standard practice would have been to send the resident for treatment. During this period, the only interventions provided were neuro checks and continued pain management, with no specific care for the fracture. The resident was eventually sent to the emergency department at her request, where a splint was applied. The facility's fall management policy required appropriate care for injuries resulting from falls, but timely interventions to manage the fracture were not implemented, resulting in a delay in treatment.