Failure to Notify Nurse and Assess Resident After Fall Leads to Undetected Hip Fracture
Penalty
Summary
Staff failed to provide care consistent with professional standards when, after a resident became unsteady during a transfer and was lowered to the floor by a CNA, two CNAs transferred the resident from the floor to the toilet without first notifying a nurse or having the resident assessed for injury. Both CNAs stated in interviews that they did not consider the incident a fall and therefore did not call for the nurse before moving the resident. Facility policy and CNA job descriptions require that all changes in a resident's condition, including falls or being lowered to the floor, be reported to the nurse immediately and that staff follow established procedures for such events. The resident involved had significant medical conditions, including dementia, cognitive communication deficit, bone disorders, rheumatoid arthritis, and hypertensive heart disease, and was assessed as severely cognitively impaired and at moderate risk for falls. After being transferred to the toilet by the CNAs, the resident exhibited a sudden change in condition, including pallor, diaphoresis, and severe pain, prompting the CNAs to then call for the nurse. Upon assessment, the nurse found the resident in significant distress and unable to identify the location of pain, leading to a decision to send the resident to the hospital. Subsequent hospital evaluation revealed that the resident had sustained an acute comminuted left femoral intertrochanteric fracture. Interviews with the nurse and the Director of Nursing confirmed that the CNAs did not follow facility policy, which defines being lowered to the floor as a fall and requires nurse assessment before moving the resident. The deficiency was the failure of staff to notify and involve nursing assessment prior to moving a resident after a fall or being lowered to the floor, resulting in delayed identification of a serious injury.