Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice following a fall, specifically by not conducting timely and thorough assessments after changes in the resident's condition. The resident, who had diagnoses including right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities, experienced a fall in the shower resulting in a laceration above the right eye and an abrasion to the right knee. After returning from the emergency room, the resident began to complain of right knee and leg pain and was placed in a wheelchair for safety. Despite these complaints and a recommendation for the physician to evaluate the leg, documentation shows that nursing staff did not perform or document comprehensive assessments of the right leg on multiple occasions over several days as the resident's pain and functional status worsened. Throughout the days following the fall, the resident exhibited increasing pain, difficulty with ambulation, and changes in mobility, including refusal to walk, reliance on a wheelchair, and eventually inability to stand without assistance. Nursing notes repeatedly failed to document assessments of the right leg even when pain was reported by the resident or observed by staff. It was not until several days after the initial fall, when the resident's right leg appeared shorter, discolored, and rotated, that an x-ray was ordered, revealing a right femoral neck fracture. Prior to this, only a right knee x-ray had been obtained, which was negative for injury, and the resident continued to experience significant pain and decreased mobility. Interviews with facility staff, including the PT and DON, confirmed that the resident's pain and functional decline were not adequately assessed or addressed in a timely manner. The DON acknowledged that no further assessments were completed by nurses when the resident's right leg pain increased and his functional status changed, until the significant physical changes were observed. This lack of timely and thorough assessment delayed the diagnosis and treatment of the resident's fractured right hip.