Failure to Provide Timely Assessment and Intervention After Resident Fall
Penalty
Summary
Staff failed to provide adequate and timely assessment and intervention following a resident's unwitnessed fall during the overnight shift. The resident, who had a history of congestive heart failure, impaired balance, and moderate cognitive deficit, was found on the floor after attempting to go to the bathroom. Initial assessment noted pain in the left leg, and Tylenol was administered. However, the nurse did not contact the on-call physician or the family, and the resident was transferred back to a recliner without further immediate medical evaluation. Subsequent monitoring throughout the night revealed ongoing pain and an inability to bear weight on the left leg, but no additional vital signs were documented during a follow-up assessment, and the physician was not notified until the morning shift. The nurse reported attempting to contact the DON but did not reach them and instead sent a fax to the physician. The resident's condition deteriorated, with a significant drop in blood pressure recorded in the early morning. It was only after the morning nurse assessed the resident and found severe pain with range of motion that the physician was contacted and the resident was sent to the hospital. At the hospital, the resident was diagnosed with a closed intertrochanteric fracture of the left hip, hypotension, and sepsis. The resident's condition rapidly declined, leading to admission to the ICU and subsequent death. Facility policy required immediate and ongoing neuro checks and vital signs after unwitnessed falls, as well as prompt physician notification for suspected fractures or significant pain, but these procedures were not followed in this case.