Failure to Report Fall, Assess Pain, and Arrange Follow-Up Care After Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely pain assessments and follow-up care for a resident with significant medical needs, including hemiplegia, vascular dementia, and aphasia. The resident experienced a slip during a transfer from a shower chair to a wheelchair, which was not reported as a fall by the staff involved. There was no documentation of the incident, pain, or skin assessments in the resident's records for the relevant period. The incident was only brought to the facility's attention after the resident and family reported ongoing pain, leading to a delayed diagnosis of a comminuted fracture in the left humeral bone, which went undetected for 11 days. The staff involved in the transfer did not use a gait belt and did not report the slip or any potential injury, as they believed the resident had not fallen and showed no immediate signs of pain or injury. The lack of reporting meant that the incident was not entered into the facility's accident log, and no immediate medical evaluation or x-ray was performed. The resident continued to experience pain, which was eventually communicated to hospice staff, who then notified the facility nurse and ordered pain medication. However, the underlying injury remained undiagnosed until the family intervened and requested further assessment. Additionally, after the resident was hospitalized and discharged with an order for an orthopedic follow-up, the facility failed to arrange the required appointment. There was no documentation that the hospice agency had been contacted regarding the follow-up, and the appointment was not made for several months. Interviews with facility staff revealed confusion over responsibilities for arranging such appointments, particularly in the absence of the social worker, resulting in a prolonged lack of necessary specialist care for the resident.