Failure to Protect Resident from Neglect and Delayed Medical Response After Fall
Penalty
Summary
A resident who primarily spoke Spanish experienced a fall during a staff-assisted transfer, resulting in immediate pain to her right knee. The nursing supervisor was informed of the fall and the resident's pain, but did not report the incident or the pain to a medical provider. There was no evidence that staff used an interpreter to accurately assess the resident's condition or pain level at the time. The lack of effective communication among staff led to a delay in notifying a medical provider about the fall and the resident's pain until the following day. When the medical provider was finally notified, orders were given for an x-ray and ibuprofen for pain management. The x-ray, which revealed acute fractures of the proximal tibia and fibula, was completed, but the results were not communicated to a medical provider until the next day. During this period, the resident continued to experience significant pain, which was not effectively managed, as the first administration of pain medication was delayed and proved ineffective. The resident reported, through an interpreter days later, that no one had asked her if she was hurt after the fall and that she was simply put back into bed. The deficiencies identified included failure to protect the resident from neglect, failure to notify the physician of the fall and subsequent pain, inadequate assessment and documentation following the fall, failure to provide a safe transfer, and ineffective pain management. The resident ultimately required hospitalization for her injuries, and orthopedic recommendations included a hinged knee brace and non-weight bearing status for the affected leg. Facility leadership declined to comment on whether the incident constituted neglect.