Failure to Follow Physician's Order for Hospital Evaluation After Resident Fall
Penalty
Summary
The facility failed to follow a physician's order for a resident who experienced a fall from a mechanical lift. After the fall, the resident was found on the floor, covered with a blanket, and was assessed by an LPN. The resident, who had a history of cerebral infarction, Alzheimer's disease, hemiplegia, and other significant medical conditions, complained of pain in the shoulders and left hip. The physician was notified and gave a direct order to send the resident to the hospital for x-rays and evaluation. Despite the physician's order, facility administration instructed staff not to send the resident to the hospital, but instead to use mobile x-ray services at the facility. The LPN communicated this change to the physician, who reluctantly agreed to the use of mobile x-rays only if they could be performed within the hour, but expressed disagreement with the decision, stating that hospital x-rays are superior and that residents who fall from such a height should always be sent to the hospital for evaluation. The medical director and DON both stated that physician orders are expected to be followed, and the administrator indicated a preference for using contracted mobile x-ray services. The deficiency occurred because the facility did not adhere to the physician's explicit order to send the resident to the hospital following a significant fall, instead substituting mobile x-rays at the facility. This action was taken despite the physician's and medical director's expectations that such orders be followed, and without documented justification for not following the original order.