Failure to Provide Post-Fall Assessment, Splint Care Orders, and Therapy Coordination
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures of the right lower leg and right hand. The resident, who was cognitively intact and able to communicate needs, experienced a fall in the bathroom after being startled by cockroaches. Following the fall, facility staff did not initiate a Change of Condition (COC) form, notify the physician, or complete a post-fall assessment as required by facility policy. There was no documentation of a comprehensive assessment, physician notification, or monitoring for post-fall complications, despite staff interviews confirming these actions should have occurred. Additionally, the facility did not obtain physician orders for the care of the resident's right wrist and distal forearm splint, which had been applied during a prior hospital stay. The absence of such orders meant that staff lacked guidance on proper splint management, as confirmed by both the Assistant Director of Rehabilitation and the Director of Nursing. Facility policy required that care for prosthetic and orthotic devices be consistent with professional standards and individualized care plans, but there was no evidence that these standards were met for the resident's splint. The facility also failed to coordinate and schedule occupational and physical therapy sessions around the resident's outpatient medical appointments. As a result, the resident missed therapy sessions on days when she was out of the facility for medical appointments, and there was no documentation of attempts to reschedule or provide therapy at alternative times. The lack of coordination was acknowledged by both the rehabilitation staff and the Director of Nursing, who noted that therapy staff should have communicated with the resident and made multiple attempts to ensure therapy was provided.