Failure to Provide Timely Care and Notification After Resident Head Injury
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, dementia, and a history of falls was not provided timely services following a head injury sustained from a fall. The resident was found on the floor next to her bed with a laceration to the left side of her head after attempting to reach for a remote. Although the wound was cleansed and bacitracin applied, the resident was not immediately sent to the hospital, and neurochecks were initiated per protocol. Documentation indicated that the family and physician were notified, but interviews later revealed that family notification was delayed by several hours, and the resident's wound continued to bleed for an extended period. Observations and interviews highlighted that required fall prevention interventions, such as non-skid strips and dycem for the wheelchair, were not in place as specified in the resident's care plan. Staff interviews revealed confusion and lack of communication regarding the resident's care, with one CNA stating that the resident's head was still bleeding hours after the fall and that the resident became increasingly confused. The responsible party also observed ongoing bleeding and confusion, and noted that neurochecks were not performed during her visit. The resident was eventually sent to the emergency department after a change in neurological status was observed, where she received four staples to her head. Further review of facility policy confirmed that both the physician and family should be notified promptly after any incident resulting in injury or change in condition. Staff interviews, including those with the DON and ADON, confirmed that urgent incidents should take precedence over routine tasks such as medication pass, and that the family should be notified as soon as the resident is stable. The failure to provide timely medical attention, ensure fall prevention interventions were in place, and promptly notify the family constituted the deficiency identified in this report.