Failure to Assess and Communicate Change in Condition After Fall
Penalty
Summary
The facility failed to provide ongoing assessments and appropriate medical intervention following a resident's fall. After the fall, staff did not identify or respond to significant changes in the resident's condition, including pain, inability to bear weight, one leg appearing shorter than the other, and external rotation of the leg. These signs, which required medical evaluation and treatment, were not recognized or communicated effectively among staff. Additionally, the facility did not notify the provider of the resident's change in condition or the results of an x-ray that revealed an acute impacted left femoral neck fracture until after hours, delaying necessary medical attention. Record review and interviews with staff, responsible party, hospice nurse, physician, and medical director confirmed these failures. The lack of timely assessment, inadequate communication, and failure to notify the provider of critical changes and diagnostic results contributed to the delay in treatment for the resident's fracture. These deficiencies were identified for one of three residents reviewed for abuse, neglect, and post-fall assessment.