Failure to Timely Notify Physician of Significant Injury After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of diagnostic results for a resident who experienced an unwitnessed fall resulting in a shoulder fracture. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder, and a history of repeated falls, was found to have a fracture dislocation of the left shoulder on X-ray. The care plan required immediate provider notification for falls with significant injury. However, after the X-ray results were received, the LPN did not notify the physician directly but instead gave the results to the DON, as per protocol at the time. The Medical Director later stated he was not informed of the X-ray findings until two days after the results were available and indicated that, had he been notified, he would have sent the resident to the hospital for evaluation and treatment. The facility's policy required immediate practitioner notification by phone when a fall resulted in significant injury. The failure to notify the physician promptly led to a delay in appropriate medical evaluation and intervention for the resident's injury.