Delay in Hospital Transfer Following Unrecognized Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, muscle weakness, difficulty walking, altered mental status, and prior falls suffered a right hip fracture after a fall. The resident was found on the floor, and an X-ray was ordered, which showed a questionable nondisplaced fracture of the right femoral neck. Despite the X-ray findings and the resident's ongoing pain, the resident was not transferred to the hospital until the following day. The facility's Discharge and Transfer Policy did not provide clear guidance on emergency transfers, and staff interviews revealed confusion regarding the appropriate response to such incidents. Nursing staff reported making multiple attempts to contact the physician and nurse practitioner without success, and the resident remained in pain until assessed by the nurse practitioner the next morning. The medical director stated that residents with pain or tenderness after a fall should be sent out immediately, but this did not occur. The delay in recognizing and treating the hip fracture resulted in the resident requiring surgery after eventual transfer to the hospital.