Failure to Notify Physician and Respond to Resident's Change in Condition During Painful Transfer
Penalty
Summary
The facility failed to communicate with the physician and obtain further instructions when a resident, who had recently undergone a total left knee replacement and had a history of rheumatoid arthritis, gout, osteoporosis, and muscle weakness, was experiencing pain and difficulty during transfers. The resident was admitted for rehabilitation and had specific transfer recommendations from physical therapy, including the use of a mechanical lift when fatigued or unable to safely perform a scoot transfer. On the evening in question, the resident refused the mechanical lift and attempted to transfer with staff assistance, resulting in significant pain and a loud scream during the process. Despite these events, the nursing staff did not contact the physician for further guidance or assessment. Following the painful transfer, the resident repeatedly requested to speak to a supervisor and later asked to be sent to the hospital due to ongoing pain. The nurse on duty did not respond promptly to these requests, nor did he notify the physician of the resident's complaints or her desire to go to the hospital. The resident ultimately called 911 herself after her requests were not addressed, and was transported to the hospital where imaging revealed a periprosthetic patellar fracture. Documentation and interviews confirmed that the physician was not notified of the resident's change in condition or her requests for medical evaluation prior to her self-initiated transfer to the hospital. Interviews with staff, the resident, and the facility's medical director confirmed that there was a lack of communication with the physician regarding the resident's pain, difficulty with transfer, and her request for hospital evaluation. The medical director stated that he should have been notified of the decrease in function and pain, and that appropriate interventions could have been initiated if he had been informed. The deficiency centers on the facility's failure to notify the physician and obtain further instructions in response to the resident's change in condition and expressed needs.