Failure to Notify Physician of Delay in Emergent Transfer After Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the primary physician regarding a delay in transferring a resident to the hospital after a significant change in condition. The resident, who had a history of hip fracture, dementia, osteoporosis, muscle weakness, and previous falls, sustained a fall resulting in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status. The physician was initially notified and ordered an emergent transfer via 911, but the resident's family member refused the immediate transfer and requested to wait until arrival at the facility, causing a delay of approximately 30 minutes before 911 was called. During this period, there was no documented evidence that the physician was informed of the family member's refusal or the delay in executing the transfer order. Interviews with staff, including the RN involved and the Director of Nursing, confirmed that the facility's policy required physician notification when there is a refusal of care or a need to significantly alter treatment, such as delaying an emergent transfer. The staff acknowledged that the physician should have been notified of the delay, but this did not occur. Facility policies reviewed indicated that the physician must be informed of accidents resulting in injury, significant changes in treatment, and decisions to transfer or discharge a resident. The failure to notify the physician of the delay in transfer, as required by policy, resulted in a deficiency related to the immediate notification of the resident's physician in situations affecting the resident's health and treatment.