Failure to Timely Notify Clinician and Transfer Resident After Hip Fracture
Penalty
Summary
Staff failed to provide care and services in accordance with professional standards of practice for a resident who was admitted with neuropathy and COPD. The resident experienced a fall and was found on the floor complaining of severe pain, rated 10 out of 10. An X-ray performed the following day revealed a deformity of the right femoral neck consistent with a subcapital fracture, and further imaging was recommended. Documentation showed that the X-ray results were sent to the physician and placed in a box for review, but there was no record of a timely response from the physician on the day the results were received. The resident remained in pain, and staff interviews confirmed that the resident was not sent to the hospital until two days after the fall. The DON acknowledged that the delay in sending the resident to the hospital was not acceptable. Facility policy required prompt notification of the attending physician and timely transfer to a hospital or treatment center when there is a significant change in a resident's condition, such as after an accident or incident. The lack of timely clinician notification and delayed transfer to the hospital constituted a failure to meet professional standards of quality care.