Failure to Recognize and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia, who was cognitively intact and required substantial assistance for transfers and personal care, experienced a fall during a staff-assisted transfer from the toilet. The nurse aides involved did not report the fall to a nurse, and the resident was not assessed by a nurse or medical provider before being moved and transferred back to bed. The resident immediately experienced pain in her right knee, but staff did not inquire about injury or pain, nor did they document the incident or perform a comprehensive assessment at the time. Communication failures among staff further contributed to the deficiency. The night shift nurse aide learned of the resident's pain and the fall from the resident's roommate and reported it to the nursing supervisor, who then assessed the resident but did not observe significant injury at that time. The nursing supervisor instructed the assigned nurse to follow fall protocol, including contacting the physician, but there was no evidence that these steps were taken. The assigned nurse did not document the incident, perform vital signs, or complete an incident report, citing time constraints and lack of specific instructions. The night shift nurse also did not take further action, assuming the day shift nurse was responsible. The lack of timely assessment and communication led to a delay in medical evaluation and intervention. The resident continued to experience pain, and it was not until the following day that the on-call provider was notified and an x-ray was ordered. The x-ray, which revealed acute proximal tibia and fibula fractures, was not communicated to a medical provider until the next day, further delaying appropriate treatment. The resident ultimately required hospitalization and orthopedic intervention. Throughout the incident, there was a lack of documentation, failure to follow established protocols, and ineffective communication among staff, resulting in delayed recognition and treatment of a significant injury.