Failure to Timely Notify Physician of Resident's Pain After Fall
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner regarding the resident's complaints of hip pain following a fall. After the resident, who had a history of hemiplegia, muscle weakness, and limited range of motion, slid out of a shower chair and landed on the floor, staff documented the incident and noted initial complaints of right hip soreness. However, the physician was only notified that the resident had fallen, with no mention of the hip pain. The resident continued to complain of pain and received Tylenol twice on the day of the fall, but there was no documentation that the physician was informed of these ongoing complaints or the administration of pain medication. Multiple staff interviews confirmed that the resident's complaints of pain were not communicated to the physician at the time of the fall or when pain medication was administered. The resident's pain persisted, and it was not until two days later that the physician was notified of the pain, at which point an x-ray was ordered. The x-ray, performed three days after the fall, revealed a mildly displaced left femoral neck fracture. Facility protocols required nurses to notify physicians of any abnormal findings or complaints, ensuring thorough assessments and communication. Both the nurse practitioner and the Director of Nursing stated that they expected staff to notify the physician of any complaints of pain following a fall. The failure to communicate the resident's pain complaints and the need for pain medication to the physician resulted in a delay in diagnosis and treatment of the hip fracture.