Failure to Obtain Timely Medical Evaluation After Resident Fall
Penalty
Summary
The facility failed to obtain timely medical evaluation and treatment for a resident following a fall. After the fall, the resident began experiencing new onset pain, initially described as an ache and later as sharp pain, with increasing severity. Nursing staff observed right hip pain, abnormal gait, and increased confusion in the resident, but did not notify the physician until several days later. During this period, the resident also exhibited increased confusion and a decline in functional abilities, including new incontinence and increased dependence for activities of daily living. The physician was eventually notified, and x-rays revealed a displaced right femoral neck fracture. Prior to the fall, the resident was cognitively intact, ambulatory with a walker, and required only setup assistance for daily activities. Following the incident and delayed intervention, the resident's condition declined significantly, with severe cognitive impairment, loss of mobility, and total dependence on staff for care. The failure to promptly assess and treat the resident's post-fall symptoms resulted in a significant deterioration in her health status.