Failure to Timely Notify Physician After Resident Fall and Change in Condition
Penalty
Summary
The facility failed to ensure timely and complete physician notification following a resident's accident and subsequent change in condition. A resident with Myasthenia Gravis and Cerebellar Ataxia, both affecting muscle strength and mobility, fell from her wheelchair during a supervised outing when traversing a grassy area without foot pedals. The resident landed on her knees and hands, and immediately reported pain in her right hand to staff at the scene. Upon return to the facility, the resident was assessed, and initial documentation indicated minimal pain and mild swelling, with ice applied to the hand. Over the next several hours, the resident's right hand became increasingly swollen, bruised, and painful, with the resident unable to grip with the hand. Multiple staff, including CNAs and an LPN, observed and documented the worsening condition and the resident's complaints of pain. Despite these observations and the facility's policy requiring immediate physician notification for significant changes in condition, the physician was not promptly notified of the resident's increased pain and swelling. The DON directed staff to monitor the resident rather than seek further evaluation, and staff reported being discouraged from escalating concerns. It was not until the following day that the medical director was contacted and an X-ray was ordered, which revealed prominent displaced fractures in the resident's right hand. Interviews with staff and the medical director confirmed that the physician expected to be notified of such changes and would have ordered emergency evaluation if made aware of the resident's pain and swelling sooner. The delay in physician notification resulted in the resident experiencing excruciating pain and a delay in diagnosis and treatment of her injury.