Failure to Notify Provider and Family of Change in Condition After Resident Fall
Penalty
Summary
The facility failed to notify the provider of a change in condition and x-ray results after a fall for one resident who was receiving hospice services and had a history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer. The resident experienced a fall while attempting to go to the bathroom, after which staff did not document the incident, assess the resident thoroughly, or notify the physician or family. The nurse on duty was preoccupied with other tasks and did not complete the required documentation or notifications, and the fall was not entered into the electronic medical record. The resident's responsible party learned of the fall from a nurse aide the following day and observed that the resident was in pain and unable to bear weight, which was a change from her baseline. Despite these observations and being informed by the responsible party, the nurse did not perform an assessment or notify the physician. The lack of documentation and communication persisted, and the resident continued to experience pain and functional decline without appropriate medical intervention or notification to the provider or family. It was not until two days after the fall, when the hospice nurse was notified by the responsible party, that an assessment was performed and a STAT x-ray was ordered, revealing an acute impacted left femoral neck fracture. The x-ray results were received at the facility but were not promptly communicated to the provider, with the on-call provider only being notified after hours. The delay in notification and lack of timely assessment and documentation resulted in a significant delay in appropriate care for the resident.