Failure to Provide Timely Treatment for Change in Condition After Fall
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage and recent craniotomy was not provided timely treatment following a fall and subsequent change in condition. After being admitted to the facility with severe cognitive impairment, the resident experienced a fall, hitting his head and sustaining facial injuries. Although neurological checks were initiated and the nurse practitioner was notified, the resident began to exhibit significant changes in mental status, including increased lethargy, inability to wake for medications or meals, slurred speech, and decreased responsiveness over the following days. Despite these clear signs of neurological decline, the facility staff did not escalate care or send the resident to the hospital in a timely manner. Documentation shows that the resident's condition worsened, with persistent lethargy and confusion, and therapy notes indicated a marked decline in functional status. The on-call nurse practitioner was notified but only advised holding medications and monitoring, without further intervention. The resident's family expressed concern and ultimately insisted on hospital transfer, at which point the resident was found to have a large subdural hematoma with midline shift, requiring emergency craniotomy and intubation. Interviews with facility staff revealed that the change in the resident's condition was recognized but not acted upon appropriately, and there was a lack of escalation to higher-level providers or the medical director. The facility failed to identify the seriousness of the resident's symptoms and did not implement any corrective measures following the incident, resulting in a delay in treatment for a life-threatening condition.