Failure to Ensure Timely Physician Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to ensure a timely physician assessment was completed after a resident experienced a fall. The resident, who had a history of anemia, renal failure, and osteoarthritis, was admitted and later readmitted to the facility. On the evening of the fall, an LPN was called to the resident's room after the resident rolled out of bed during care. Subsequent clinical records documented ongoing bruising to the resident's right shin over several days following the incident. Despite these findings, there was no evidence in the clinical record that a physician assessed the resident's fall or the resulting bruising in a timely manner. The resident was later admitted to the hospital with significant medical concerns, including a critically low hemoglobin level and supratherapeutic INR, requiring a blood transfusion. A late entry progress note by the Medical Director, entered more than a month after the fall, did not address the fall or the bruising. Facility leadership confirmed that a timely physician assessment was not completed after the fall.