Failure to Ensure Timely Clinical Assessment and Response After Resident Falls
Penalty
Summary
A deficiency occurred when a resident with a history of right femur fracture, muscle atrophy, and osteoarthritis experienced a fall while attempting to get out of bed. The DON witnessed the fall and assessed the resident, who complained of hip pain. Orders were obtained for a right hip x-ray and pain medication. The resident was transferred back to bed using a mechanical lift and later placed in a reclining chair near the nurse's station due to repeated attempts to get out of bed. The x-ray was not ordered stat, and the resident remained in the facility while awaiting imaging. The x-ray, completed the following day, revealed an acute right femoral intertrochanteric fracture, but the results were not reviewed or acted upon until the next day, resulting in a delay in transferring the resident to the hospital for treatment. Another deficiency involved a resident who was severely cognitively impaired, dependent for all ADLs, and on anticoagulation therapy. After returning from a dialysis appointment, the resident slid out of her wheelchair in a transport van when the driver hit a bump. Two nursing assistants responded to the driver's request for help and lifted the resident back into her wheelchair without notifying a nurse or having a qualified assessment for injuries prior to moving her. The nurse was notified only after the resident was brought back into the facility, at which point an assessment was performed and the resident was sent to the hospital for evaluation. In both cases, the facility failed to ensure that residents received timely and appropriate clinical assessments following falls. For the first resident, there was a failure to promptly review and act on diagnostic results, leading to a delay in necessary medical intervention. For the second resident, unqualified staff moved the resident after a fall without a nurse's assessment, which did not follow protocol for post-fall evaluation, especially given the resident's high risk for injury due to anticoagulant use and physical limitations.