Failure to Timely Assess and Treat New Shoulder Injury
Penalty
Summary
Facility staff failed to assess, intervene, and implement timely treatment for a resident who was found with new bruising to her left shoulder. The resident, who was severely cognitively impaired, nonverbal, and dependent on staff for all care due to Alzheimer's disease, was discovered with a large, purple bruise on her left upper arm during the early morning hours. Despite this significant change in condition, facility staff did not notify the resident's physician or nurse practitioner, nor did they attempt to obtain an order for an X-ray. Instead, staff notified the hospice agency and waited for their direction, resulting in a delay of over 24 hours before an X-ray was performed. The X-ray, eventually ordered by the hospice nurse after her own assessment, revealed a dislocated left shoulder with a possible glenoid fracture. The resident was subsequently sent to the hospital for evaluation, where surgical intervention was recommended but declined by the resident's power of attorney. The resident was returned to the facility with orders for conservative management and comfort care. Throughout this period, facility progress notes showed no documentation of reassessment of the injury, no follow-up with the mobile X-ray company to expedite imaging, and no direct communication with the resident's primary medical providers regarding the acute change in condition. Interviews with facility staff, including the RN, ADON, and DON, confirmed that none of them contacted the resident's physician or nurse practitioner after discovering the injury. Staff indicated they were waiting for hospice to take the lead, despite facility policy requiring immediate notification of the attending physician for acute changes in condition. The facility's own policy emphasized the need for prompt assessment, physician notification, and documentation when a resident experiences an acute change, none of which were followed in this case.