Failure to Immediately Notify Provider of Resident's Change in Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify the provider after a resident developed swelling and increased pain in the left hip following a fall that had occurred two days prior. The resident, who had a history of dementia, muscle weakness, unsteadiness, repeated falls, and osteopenia, was identified as a high fall risk. After the fall, the initial post-fall assessment did not include a check of the range of motion or rotation of extremities, and although the family and provider were notified of the fall, no new orders were documented and the resident was not transferred for further evaluation at that time. Over the next two days, the resident exhibited signs of increased pain, swelling, and difficulty with mobility and eating, as observed by nurse aides and nursing staff. Despite these changes, there was a delay in both the assessment by a registered nurse and in notifying the provider of the resident's worsening condition. The LPN on duty documented the findings several hours after being notified and only sent a text message to the provider, without receiving a timely response. The RN who was informed of the resident's pain and abnormal behavior did not assess the resident or notify the provider as required. The provider was eventually notified of the resident's increased pain and swelling, but there was a significant delay before an order for an x-ray was obtained and completed. The x-ray revealed acute, mildly displaced fractures of the left pelvis. Facility policy required prompt assessment and provider notification for changes in condition, but this was not followed, resulting in delayed medical intervention for the resident.