Failure to Report Change of Condition Results in Delayed Identification of Hip Fracture
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to demonstrate competency in recognizing and reporting a change of condition (COC) for a resident who developed new right hip pain and decreased range of motion (ROM). The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was previously able to ambulate and perform activities of daily living (ADLs) independently. On the morning in question, the resident was unable to move his right leg, required increased assistance from a certified nursing assistant (CNA), and reported significant pain. The CNA notified the LVN, who assessed the resident but did not observe bruising or swelling and attributed the pain to a possible minor cause, administering Tylenol and informing the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. Despite the resident's new symptoms and decreased ROM, the LVN did not report the COC to the Director of Nursing (DON), who was the supervisor on duty. The facility's policy and the LVN's job description required that such incidents or unusual occurrences be reported to supervisory staff for further assessment and investigation. The DON later stated that had she been informed, she would have conducted a comprehensive assessment and recommended further diagnostic evaluation, such as an X-ray. The lack of communication prevented timely intervention and a thorough investigation into the cause of the resident's symptoms. Subsequently, the resident was transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later, necessitating surgery. Upon readmission to the facility, the DON became aware of the fracture and reviewed the records, confirming that the LVN had not reported the initial COC. The incident was classified as an injury of unknown origin, as the cause was unwitnessed and unexplained, and the resident was unable to provide an account of how the injury occurred.