Failure to Recognize and Respond to Critical Head Injury Following Resident Fall
Penalty
Summary
The facility failed to accurately assess a critical clinical sign (Battle sign) and did not implement its change in condition policy by failing to immediately activate EMS for a resident who exhibited an acute change in mental status following a fall. The resident was first observed by an LPN with discoloration around the left eye and behind the left ear after reporting a fall during the previous night. The LPN assessed the resident, initiated neurological checks, and notified the physician, who ordered a routine facial x-ray. The resident was placed on observation, and staff were instructed not to allow her to leave the nursing unit alone. Despite these instructions, the resident was later allowed to go to the patio for a smoke break without staff accompaniment. While on the patio, the resident fell again, hitting her head. After being brought back to the nursing unit in a wheelchair, she was lethargic, had abnormal vital signs, and required supplemental oxygen. The nurse on duty called EMS only after the resident became unresponsive in her room, at which point CPR was initiated. EMS arrived to find the resident unresponsive but with a pulse, and noted significant head trauma, including Battle sign and a hematoma. The EMS report indicated that staff had observed the resident with these injuries earlier in the day, following a previous fall. Upon arrival at the hospital, the resident was minimally responsive, with fixed and dilated pupils, and was diagnosed with a large acute subdural hematoma with midline shift and herniation. The hospital record confirmed the presence of Battle sign and severe brain injury. The facility's director of nursing acknowledged that the resident should have been transferred to the hospital when the initial injuries were observed. The facility's policy required immediate EMS activation in medical emergencies, but this was not followed, resulting in a delay in treatment for the resident.