Failure to Assess and Notify Provider After Resident Fall Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, muscle weakness, unsteadiness, pain, and repeated falls was not properly assessed following a fall. The resident, identified as a high fall risk with a care plan in place for mobility assistance and safety interventions, experienced a fall after attempting to self-ambulate. The initial post-fall evaluation documented a head injury and a skin tear but did not include a thorough assessment of the extremities, specifically omitting range of motion or rotation checks. Although the family and provider were notified, no new orders were issued at that time. In the days following the fall, the resident exhibited increased pain, swelling, and edema in the left hip, with pain scores escalating to eight out of ten. Despite these symptoms, documentation failed to show that a focused assessment of the left hip was conducted immediately. Nursing staff delayed notifying the provider and did not document their findings promptly. Communication between shifts was inconsistent, with nurse aides and LPNs reporting pain and functional decline, but the responsible RN did not assess the resident or notify the provider as required by facility policy. The resident's condition continued to deteriorate, with ongoing pain, refusal to eat, and difficulty with mobility. Eventually, an x-ray revealed acute, mildly displaced fractures of the left pelvis. Interviews confirmed that staff recognized abnormal pain and behavior but did not follow established protocols for assessment and provider notification. Facility policy required prompt assessment and notification for changes in condition, which was not followed in this case.