Failure to Notify Physician of Resident's Change in Condition After Fall
Penalty
Summary
Facility staff failed to notify a resident's Primary Care Practitioner (PCP) of significant changes in the resident's condition following a fall. The resident, who had a history of cancer, anemia, dementia, seizure disorder, anxiety, depression, and psychotic disorder, experienced a fall resulting in a superficial head cut and reported severe back pain. Over the next several days, the resident continued to complain of back and neck pain, with pain levels remaining high and little relief from prescribed medications. Documentation showed that the resident's pain persisted and worsened, with additional symptoms such as inability to turn in bed without yelling in pain. Despite these ongoing and escalating symptoms, there was no evidence in the medical record that the facility staff notified the resident's PCP of the increased back pain or changes in condition until four days after the fall, when the resident became lethargic, unresponsive, and was subsequently transferred to the hospital for a brain bleed. The facility's policy required prompt notification of the physician and documentation of such changes, but this was not followed in this case.