Failure to Provide Timely Emergency Care and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide timely emergency services and thorough documentation for three residents who experienced falls, resulting in a deficiency related to quality of care. One resident, who was on a blood thinning medication, suffered an unwitnessed fall with a head injury. Despite having a laceration above the eye and being at high risk for intracranial bleeding, the resident was not sent for immediate medical evaluation. Instead, the resident was monitored in the facility, and only after a significant change in condition, including delayed response and unequal pupils, was the resident transferred to the emergency department. Hospital records confirmed a large subdural hematoma requiring emergency surgery, and the resident was later placed on comfort care. For two other residents who experienced falls, the facility's response was inconsistent. Both residents were not on blood thinners but were sent to the emergency department for evaluation after their falls, one with a head laceration and the other with head pain. However, the facility failed to complete required alert charting and post-fall monitoring every shift for 72 hours as outlined in facility policy. Documentation was missing or incomplete for multiple falls, and alert charting was not consistently performed as expected by facility leadership. Interviews with staff confirmed that the expectation was for alert charting to be completed every shift for 72 hours following a fall, but this was not consistently done. The deficiency was further supported by a review of facility policies and external clinical guidelines, which emphasize the need for rapid assessment and intervention for residents on anticoagulants who sustain head injuries. The lack of timely emergency response and incomplete documentation placed residents at risk for medical complications and delayed care.