Failure to Timely Assess, Intervene, and Escalate Care After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to ensure that staff appropriately assessed, monitored, intervened, and notified the family in a timely manner following a resident's unwitnessed fall, which resulted in a brain bleed, skull fracture, and eventual death. After the fall, the resident was found with visible facial bruising, swelling around the eyes, a bruised nose, and bleeding from the hand, but denied pain and hitting his head. Despite these injuries and the unwitnessed nature of the fall, staff did not immediately contact a physician or the resident's family, nor did they send the resident to the emergency room for evaluation. Instead, the resident was monitored in the facility, and only telehealth (E-Care) providers were consulted, who did not identify the need for urgent in-person evaluation. As the resident's condition deteriorated, including the onset of headache, nausea, vomiting, elevated blood pressure, and hypoxia, staff continued to follow telehealth provider recommendations, which included administering medications and ordering diagnostic tests, but did not escalate care to an emergency room visit. The nurse on duty believed she required a physician's order to send the resident to the ER and did not act on her own clinical judgment, despite concerns voiced by other staff members. Neurological checks were not performed according to protocol, and there was a lack of clear communication and escalation through the chain of command, even as the resident's symptoms worsened. The resident was not transferred to the emergency room until approximately nine hours after the fall, when the primary care provider arrived and recognized the severity of the situation. At the hospital, the resident was diagnosed with multiple skull fractures, brain bleeds, and herniation, and subsequently died. The facility's policies required immediate assessment, notification, and escalation for head injuries or changes in condition, but these were not followed. Staff interviews revealed confusion about the need for a physician's order to send a resident to the ER and a lack of empowerment to act on clinical judgment in emergent situations.