Failure to Assess and Communicate After Resident Fall Resulting in Delayed Fracture Diagnosis
Penalty
Summary
A deficiency occurred when facility staff failed to provide ongoing assessments and appropriate medical evaluation and treatment following a resident's fall. After the resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer, fell while attempting to go to the bathroom, the assigned nurse and nurse aide assisted her back to bed but did not document the incident, notify the physician or family, or conduct thorough post-fall assessments. The nurse reported being too busy to document or notify anyone, and there was no record of the fall or subsequent assessments in the electronic medical record for that shift. The resident experienced pain and a significant change in her ability to bear weight and participate in activities of daily living following the fall. Despite these changes, staff across multiple shifts were not informed of the fall, and the resident's pain was not adequately assessed or managed. Communication failures between shifts and lack of documentation led to delays in recognizing the severity of the resident's condition. The family and hospice nurse were the first to escalate concerns after observing the resident's increased pain and inability to bear weight, which prompted further assessment and a physician-ordered x-ray. The x-ray revealed an acute impacted left femoral neck fracture, but this diagnosis and the need for medical intervention were not promptly communicated to the family or acted upon by facility staff. The resident continued to experience pain and functional decline until the fracture was identified and she was transferred to the hospital for surgical repair. Throughout this period, there were repeated failures in assessment, documentation, communication, and timely notification of changes in the resident's condition.