Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including severe cognitive impairment, malnutrition, and muscle weakness, experienced an unwitnessed fall in their room. The resident, who was independently ambulatory with a walker, was found on the floor complaining of right groin and thigh pain and was unable to stand or perform baseline activities. Despite these symptoms, the initial assessment by the LPN did not result in immediate imaging or transfer to the hospital. Instead, the LPN ordered imaging through an outside company, which was not scheduled as a stat (immediate) order. The imaging company was unable to perform the imaging on the same day due to workload, and the LPN did not notify the physician of this delay or the resident's ongoing pain and inability to bear weight. Multiple CNAs reported the resident's continued inability to perform normal functions and persistent pain to the LPN, but no further action was taken that day. The resident remained in bed, in pain, and without definitive diagnostic evaluation for over 24 hours after the fall. It was not until the following day, after the imaging was finally completed and showed a displaced right femoral neck fracture, that the resident was transferred to the hospital for further evaluation and care. Interviews with staff and review of records confirmed that the imaging order was not placed as stat, the physician was not kept informed of the delay or the resident's worsening condition, and the resident did not receive timely treatment in accordance with professional standards of practice after the fall.