Failure to Notify Physician of Resident's Change in Condition After Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who required dependent care. The resident, who had morbid obesity and osteoarthritis, needed staff assistance for bed mobility. During morning care, as a CNA assisted the resident to roll, the resident's leg fell off the bed. The CNA attempted to reposition the resident, but due to the resident's large size and the CNA's small stature, both the resident and the CNA fell from the bed to the floor. The resident's legs crossed during the fall, and the impact resulted in fractures to both femurs. Following the fall, the resident initially denied pain but later reported increasing pain, which was documented as 2/10 and then 8/10 on the pain scale. The LPN provided acetaminophen and informed the nurse practitioner of left thigh pain, leading to an X-ray order. However, the nurse practitioner later stated she was not notified of the resident's increased pain level of 8/10. The deficiency centers on the facility's failure to promptly notify the physician of the resident's significant change in condition, specifically the escalation in pain following the fall and prior to the X-ray results.