Failure to Assess and Treat Resident After Fall Resulting in Fracture
Penalty
Summary
Staff failed to assess a resident after a reported fall, did not provide timely treatment, and did not implement or follow physician orders for care following the identification of a fall with injury. The resident, who had diagnoses including heart disease, macular degeneration, muscle weakness, and was at risk for falls, self-reported a fall that occurred two days prior to being evaluated by clinical staff. The fall was not reported by staff at the time it occurred, and no assessment or documentation was completed immediately following the incident. The resident subsequently developed pain, swelling, and bruising to the left arm, which was not addressed until the resident reported these symptoms to a nurse practitioner. Despite clear physician orders to obtain an x-ray, immobilize the arm, and provide RICE (Rest, Ice, Compression, Elevation) treatment, staff did not document or provide these interventions in a timely manner. The x-ray, when eventually performed, revealed an acute distal radial metaphysis fracture. The resident was sent to the emergency room for further evaluation and returned with a splint, but staff continued to fail in documenting assessments, treatments, or the application of the prescribed brace or sling. Interviews with staff and the resident confirmed that the resident was often left without the prescribed immobilization device and continued to experience pain. Multiple staff interviews revealed a lack of communication and failure to follow protocol regarding fall reporting, assessment, and implementation of physician orders. The charge nurse was not informed of the fall, and staff did not provide or document the required treatments. The resident's pain and injury went unaddressed for an extended period, and staff were unaware of the current treatment plan or the location of the prescribed immobilization devices. The facility's own policies required assessment and intervention after any fall, but these were not followed in this case.