Failure to Promptly Notify Physician of Change in Condition Resulting in Delayed Diagnosis of Hip Fracture
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a physician of a resident's significant change in condition and decline in mobility, resulting in prolonged discomfort and pain. The resident, who was cognitively impaired and had a history of falls, muscle weakness, and difficulty walking, began experiencing new onset pain in her left lower extremity during physical therapy. Over the course of several days, multiple physical therapy assistants observed and documented a marked decline in the resident's ability to bear weight and increased pain, with the resident herself expressing concern that her hip might be broken. Despite these observations, the nursing staff did not promptly notify the physician or obtain an order for an x-ray. A physical therapy assistant reported the change in condition and requested an x-ray to the assigned LPN, but the LPN did not follow through with physician notification or documentation of the change. The Director of Nursing was not made aware of the situation until the resident's daughter raised concerns at the nurses' station, at which point a STAT x-ray was ordered and a left intertrochanteric hip fracture was identified. The facility's policy required prompt notification of the physician and the resident's representative in the event of a significant change in condition. However, the lack of timely communication and documentation by the nursing staff led to a delay in diagnosis and treatment of the resident's hip fracture, as confirmed by interviews with therapy staff, the Director of Nursing, and the resident's daughter.