Failure to Timely Assess and Report Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a complex medical history, including Parkinson's disease, chronic respiratory failure, severe malnutrition, and cognitive impairment, experienced a fall in the dining room that was not witnessed by nursing staff. The resident was dependent on staff for mobility and required substantial assistance for activities of daily living. After the fall, the resident was found on the floor by a CNA, but the incident was not immediately reported to nursing staff, and the resident was moved without a nursing assessment. The fall was only brought to the attention of nursing staff the following day, at which point a range of motion and skin assessment was performed, and the resident was noted to be in pain and resistant to having her arm touched. Subsequent evaluation by hospice and hospital staff revealed that the resident had sustained multiple rib fractures and a fractured clavicle, as well as a urinary tract infection. The delay in notifying nursing staff and the lack of immediate assessment resulted in the resident enduring pain for over a day before appropriate medical intervention was initiated. Interviews with facility staff confirmed that the expected protocol was for staff to notify nursing immediately and not to move a resident after a fall until assessed by a nurse, but this protocol was not followed in this instance. Facility policy required that all falls be promptly evaluated for injury, with the physician and emergency contact notified, and an incident report completed. However, in this case, the failure to follow these procedures led to a significant delay in the identification and treatment of the resident's injuries. The deficiency centers on the lack of timely assessment and communication following the resident's fall, contrary to facility policy and standard care expectations.