Delayed Response to Acute Fracture and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-Alzheimer's dementia, and a history of stroke did not receive timely and appropriate care following a significant change in condition. The resident, who was bedbound and dependent on staff for all activities of daily living, began experiencing severe pain and swelling in the left knee. Despite multiple complaints of pain from the resident and reports from family members, nursing staff failed to conduct thorough assessments, document findings, or notify the physician or nurse practitioner promptly. Pain assessments were inconsistently performed, and there was a lack of documentation regarding the resident's pain and condition changes during several shifts. When the resident's pain escalated and was unrelieved by PRN pain medications, staff delayed in escalating care and obtaining necessary diagnostic imaging. An x-ray was eventually ordered and performed, revealing a displaced distal femoral shaft spiral fracture. However, after the facility received the x-ray results indicating an acute fracture, there was a delay of approximately 13 hours before the resident was transported to the hospital for emergency evaluation and surgery. During this period, staff did not immediately notify the physician or nurse practitioner, nor did they reassess or adequately monitor the resident's condition. Interviews with staff and family confirmed that the resident's pain was not effectively managed, and communication breakdowns occurred at multiple points, including failure to document assessments, notify appropriate clinical leadership, and act on critical diagnostic findings. The facility's own Director of Nursing acknowledged that the change in condition should have been recognized and acted upon much earlier, and that the delay in care could have resulted in continued pain and adverse outcomes for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) will be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.
- Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will ensure the plan is completed in full.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- All In-service sign-in sheets were requested and reviewed.
- Interviews were conducted on all shifts with staff to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them.