Failure to Immediately Notify Physician After Resident's Change in Condition Post-Fall
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following a significant change in the resident's physical status after a fall. The resident, who had a complex medical history including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. Initial assessment by staff indicated the resident was alert and reported no pain, and the physician, DON, and family were reportedly notified. However, subsequent documentation and interviews revealed that the resident exhibited a decrease in level of consciousness and episodes of vomiting, which were not promptly communicated to the medical provider. Nursing staff continued neurological checks and observed that the resident was less responsive than her baseline, requiring manual opening of her eyes for pupil assessment. Despite these concerning signs, the nurse on duty waited for the Nurse Practitioner (NP) to arrive later in the morning before taking further action, citing previous family concerns about hospital transfers and the resident's DNR status. The NP, upon being notified and assessing the resident, immediately recognized the need for hospital evaluation due to the resident's lethargy and vomiting, and arranged for transfer to the emergency room. Interviews with facility staff confirmed that there was a delay in notifying the medical provider about the resident's change in condition, particularly the decrease in responsiveness and vomiting following the fall. The DON stated that such changes should have prompted immediate physician notification. The family expressed concern that the resident was not sent to the hospital promptly, especially given her history of brain bleeds and falls. The resident was later found to have suffered a catastrophic new brain bleed and passed away several days after the incident. The facility's internal investigation did not address the failure to respond to the resident's change in condition.