Failure to Notify Physician of Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician after a resident reported a fall and was experiencing acute pain. The resident, who had a history of stroke and right-sided hemiplegia, communicated in Spanish that she had fallen in the bathroom while being assisted by two staff members. Despite the resident's clear reports of significant pain and visible signs of injury, including bruising and swelling of the right knee and shin, staff did not immediately notify a physician or initiate appropriate medical interventions. Multiple staff members became aware of the resident's pain and the reported fall, but there was confusion and lack of clear communication regarding responsibility for notifying the physician and completing post-fall assessments. The day shift Nursing Supervisor was informed of the incident but did not contact the physician, instead instructing the day shift nurse to handle the situation. The day shift nurse, having already given report to the night shift nurse, assumed the night shift nurse would complete the necessary notifications and documentation. The night shift nurse, in turn, believed the day shift nurse had already addressed the issue. As a result, no physician was notified on the day of the fall, and no immediate medical evaluation or intervention was provided. It was not until the following day, after the resident's family member called the facility to inquire about the fall and pain management, that the Nursing Supervisor contacted the on-call provider. An x-ray was then ordered, revealing acute nondisplaced fractures of the proximal tibia and fibula. The delay in physician notification and medical intervention resulted in the resident experiencing prolonged pain and a delay in receiving appropriate care, including hospitalization and orthopedic management.