Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.