Failure to Notify Physician of Significant Change After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident following a fall. The resident, who had a history of heart failure and hypertension, was found on the floor in their room and subsequently complained of pain in the right arm and hip. Despite repeated complaints of pain and administration of Tylenol for pain management, there was no documentation that the physician was notified of the fall, the new pain complaints, or the increased use of pain medication for four days. An x-ray was not ordered until four days after the fall, at which point a right hip fracture was identified. Interviews with staff and review of records confirmed that the nurse on duty did not notify the physician as required by facility policy, which mandates immediate notification of the physician for any significant change in a resident's condition. The resident and their representative both reported ongoing pain and a delay in diagnostic intervention. The Director of Nursing Services acknowledged that the expectation was for immediate physician notification following such incidents, and that this protocol was not followed in this case.