Failure to Timely Treat Displaced Shoulder Joint After Fall
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who sustained a displaced shoulder joint following a fall. The resident, who had multiple diagnoses including repeated falls, impaired cognition, and psychiatric disorders, experienced an unwitnessed fall resulting in a shoulder injury. Although the resident later reported increasing pain in her arm, and an X-ray confirmed a fracture dislocation with abnormal positioning and fracture fragments, there was no immediate action taken to address the injury. The X-ray results were reviewed, but no new orders were given, and the physician was not notified promptly as required by facility policy. The delay in notifying the attending physician and obtaining appropriate medical treatment resulted in the resident continuing to experience pain, swelling, and functional impairment for two days before being sent to the hospital. Interviews revealed that the LPN provided the X-ray results to the DON, who did not notify the medical director. The medical director confirmed he was unaware of the injury until his next visit, at which point he ordered the resident to be sent to the hospital for evaluation and treatment. Facility policy required timely physician notification and immediate medical treatment for injuries after a fall, which was not followed in this case.