Failure to Honor Resident's Request for Hospital Transfer After Fall
Penalty
Summary
A resident with a history of stroke, renal disease, and diabetes, who was cognitively intact and required a walker, experienced an unwitnessed fall in their room. Following the fall, the resident repeatedly requested to be transported to the hospital due to pain. Nursing progress notes indicate that the Medical Director was notified of the fall but did not provide an order for hospital transfer. Despite the resident's continued requests for hospital evaluation, the facility did not honor these requests because there was no physician order. Subsequently, the resident used their personal cell phone to call 911 and was transported to the hospital by Emergency Medical Services, where they were diagnosed with a closed fracture of the first lumbar vertebra and a rib fracture. The Director of Nursing Services confirmed during an interview that the expectation is to contact the physician if a resident complains of pain and acknowledged that she would have called for a hospital evaluation in such a case. However, she was unable to provide evidence that the facility honored the resident's request for transfer.