Failure to Promptly Notify Physician After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician after a resident experienced a fall that resulted in injury and pain. The resident, who had a history of complications following a right hip replacement, reported falling during a transfer when left unsupported by a nurse who went to seek assistance. Staff interviews confirmed that the established fall protocol required immediate notification of the physician and family, but the responsible staff member did not notify the on-call physician after the incident. Documentation in the resident's electronic health record did not show timely physician notification regarding the fall and the resident's increased pain. The delay in physician notification led to a delay in treatment, and the resident was later found to have sustained a fracture. Facility policy and the fall prevention program both required prompt notification of the physician and family following an accident resulting in injury. The lack of timely communication with the physician impacted the opportunity for the physician to provide directives on the resident's care, pain management, and injury assessment.