Failure to Provide Appropriate Emergency Response After Resident Fall
Penalty
Summary
A resident with a history of cancer, diabetes mellitus, hypertension, and arthritis, and who was cognitively intact, experienced a fall in their room and was found on the floor with a small amount of blood behind the head, unable to move their arms or legs. Multiple staff, including a resident assistant, LPNs, CNAs, and the activities director, observed that the resident could not sit up or maintain upper body balance and had symptoms such as nausea, vomiting, and abnormal limb movements. Despite these significant symptoms and the presence of a head injury, staff, under the direction of the former DON, lifted the resident into a wheelchair and transported them to the ER in the facility van, rather than calling emergency medical services. The decision to use the facility van was based on the perceived expense and speed compared to calling an ambulance. The facility failed to notify the nurse practitioner of the fall or the need for hospital transport, contrary to facility policy, and did not follow the established protocol to call 911 for residents requiring a higher level of care. The facility's Fall Prevention Policy required physician and family notification after a fall, which was not followed in this case. The actions and inactions of the staff resulted in actual harm to the resident, who was later diagnosed with cervical spine fractures.