Failure to Timely Report and Treat Change in Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to timely report and treat a change in condition for a resident with a complex medical history, including dementia, multiple fractures, and a high risk for falls. After a witnessed fall, the resident complained of pain, particularly when transferring, sitting, or standing, but the facility did not promptly notify the physician or obtain appropriate diagnostic testing for the new pain. Instead, staff attributed the pain to the recent fall and continued to administer routine Tylenol, while the resident's daughter repeatedly voiced concerns about the nature and persistence of the pain. Despite ongoing complaints and behavioral signs of pain, such as increased agitation and combativeness during transfers, the staff did not escalate the issue or seek further medical evaluation. The resident's daughter reported her concerns to both nurses and CNAs, but was told the pain was expected after a fall. The physician was not informed of the resident's increased pain or potential new injury, and the plan became to wait for an upcoming orthopedic appointment rather than pursue immediate assessment. The resident remained in pain for several days without a new evaluation or intervention. Eventually, at the orthopedic appointment, the resident was diagnosed with a right inferior pubic ramus fracture, which had gone unrecognized and untreated for eight days. Interviews with staff confirmed that the physician was not notified of the change in condition, and the Director of Nursing stated that she would have expected nurses to report such changes. The facility did not provide a change in condition policy for review.