Failure to Provide Timely Care and Physician Notification After Resident Fall
Penalty
Summary
A resident with 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. The resident was found on the bathroom floor by her husband and was initially assessed as alert, with no pain or apparent neurological deficits. Neurological checks were initiated, and the physician, DON, and family were notified via text. However, documentation of the neurological assessment following the fall could not be located in the medical record. Throughout the morning, the resident exhibited a change in condition, including episodes of vomiting and decreased level of consciousness. Staff noted that the resident was more lethargic than usual and required assistance to open her eyes for neurological checks. Despite these concerning symptoms, the resident was not immediately sent to the hospital. The nurse practitioner was notified later in the morning and, upon assessment, determined that the resident needed to be transported to the emergency room. The resident was sent to the hospital by a non-emergent ambulance, where she was diagnosed with a brain bleed and subsequently passed away four days later. Interviews with facility staff revealed inconsistencies in the process for documenting and escalating care for residents with changes in condition following a fall. Staff were unclear about the handling and storage of neurological check forms, and there was a delay in notifying the medical provider of the resident's deteriorating condition. The facility's investigation did not address the resident's change in condition, and the lack of timely intervention and documentation contributed to the finding of harm for the resident.