Delayed Physician Notification and Transfer Following Acute Femoral Fracture
Penalty
Summary
The facility failed to provide timely medical intervention and transfer for a resident who experienced a significant change in condition related to unmanaged pain and a delayed response to an acute right femoral fracture. Staff did not promptly notify the resident's physician after receiving a stat x-ray result indicating an acute proximal femoral fracture with soft tissue swelling. The x-ray result was received at 1:22 a.m., but the physician was not notified until 8:35 a.m., resulting in a delay of over seven hours before appropriate action was taken. During this period, the resident continued to experience severe pain and swelling, as documented by multiple pain assessments and nursing progress notes. The resident had a complex medical history, including chronic respiratory failure, ventilator dependence, osteoporosis with pathological fractures, quadriplegia, and contractures. On the day of the incident, staff observed the resident with facial grimacing, an unstable right hip, and increased pain during repositioning. Despite these findings and the subsequent x-ray confirming a fracture, the facility did not follow its own care plan and policy requirements for prompt physician notification and intervention. Pain management was inconsistent, with the resident receiving Tylenol and later Norco, but continued to exhibit signs of severe pain, including hyperventilation, moaning, and rigidity. The facility also failed to implement its policy on changes in a resident's condition, which requires immediate notification of the attending physician and resident representative upon significant changes. The delay in notification and transfer resulted in the resident experiencing unmanaged pain and increased swelling for approximately 10 hours before being transferred to a general acute care hospital. The resident ultimately underwent a surgical procedure involving removal of the femoral head and neck with hip disarticulation.