Delayed Provider Notification After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to promptly notify a provider of a resident's change in condition. The resident, who had diagnoses including dementia with behavioral disturbances, Parkinson's disease, and osteoarthritis, was dependent on staff for mobility and had a physician's order for transfer with a mechanical lift. During morning care, the resident complained of left leg pain and swelling, which was unusual for this individual. The nurse aide immediately reported these symptoms to the supervising RN, but the RN did not assess the resident until several hours later. Despite repeated notifications from the nurse aide regarding the resident's pain and swelling, the supervising RN delayed both assessment and provider notification. The resident's pain and swelling increased throughout the day, and it was not until the afternoon that the RN assessed the resident and noted significant symptoms, including a large bruise and deformity of the leg. The RN still did not notify the provider or administer pain medication until approximately eight hours after the initial complaint. Other staff, including an LPN and the DON, became involved later in the day when it was apparent the resident's condition was serious. The facility's fracture management policy required immediate stabilization and provider notification for suspected fractures, but this protocol was not followed. The delay in assessment and notification resulted in a significant delay in the resident being transferred to the hospital, where a periprosthetic femur fracture was diagnosed.