Failure to Notify Physician of Change in Resident Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician after a change in condition was identified for a resident who had a witnessed fall. The resident, with diagnoses including malignant neoplasm of the oropharynx, anxiety, and depression, had poor short- and long-term memory recall. After the fall, the resident complained of right hip and knee pain, but initial assessments and x-rays did not reveal acute injuries. The Advanced Practice Registered Nurse (APRN) was notified and ordered x-rays and neurological checks, and later evaluated the resident, instructing staff to monitor for any changes in status or symptoms. Over the following days, the resident continued to report significant right hip pain and became unable to fully extend the right leg. Although the nurse administered pain medication and informed the Nursing Supervisor, there was no documentation that the provider was notified of the resident's new inability to extend the leg, which represented a change in condition. Interviews with staff confirmed that the APRN expected to be notified of such changes and would have ordered further evaluation if informed. The Director of Nursing also confirmed that loss of range of motion should be classified as a change in condition requiring physician notification. The facility's policy required that any change in a resident's condition be reported to the physician after assessment by the charge nurse and RN supervisor. Despite this, the clinical record from the period in question did not reflect that the provider was notified when the resident was unable to fully extend the leg. The resident was later found to have a right hip proximal femoral fracture after being sent to the emergency department for worsening symptoms.