Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
Staff failed to accurately assess and respond to a resident's change in condition following a fall. The resident, who had a history of dysphagia, aphasia, stroke, gastrostomy tube, COPD, atrial fibrillation, atherosclerotic heart disease, and congestive heart failure, was found on the floor after a fall, had vomited twice, and was on anticoagulant therapy. Despite these risk factors, there was no evidence that nursing staff performed a thorough assessment, such as auscultating the lungs or assessing the abdomen, and critical information about the fall and vomiting was not communicated to the provider. Documentation and communication lapses were evident throughout the incident. The nurse practitioner was contacted but was not informed of the resident's fall, and the SBAR form was incomplete, omitting key details such as the fall and the resident's anticoagulant use. The resident continued to receive anticoagulant medication after the fall, and neurological checks were performed, but changes in vital signs and the significance of vomiting were not fully recognized or reported. Multiple staff interviews revealed assumptions that the provider was already aware of the fall, and there was a lack of clarity regarding who was responsible for communicating critical changes. The facility's policies required detailed assessment and prompt, complete communication with providers in the event of an acute change in condition, especially for residents on anticoagulants who experience a fall. However, these protocols were not followed. The resident's deteriorating condition, including elevated pulse, low oxygen saturation, and repeated vomiting, was not adequately addressed, and the provider was not given the necessary information to make informed decisions. Ultimately, the resident was found unresponsive and expired, with staff and providers acknowledging in hindsight that the resident should have been sent to the hospital and that the anticoagulant should have been held.