Delayed Hospital Transfer Following Resident Fall with Injury
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, osteoarthritis, chronic pain, and a previous left femur fracture experienced a fall resulting in pain to the left shoulder and left groin area. Documentation showed that the resident's pain level increased from 2 to 5 on a 1-10 scale following the fall, and later reached a 7. Despite these symptoms and visible signs of distress, there was a significant delay in sending the resident to the hospital. X-rays were ordered but not completed until later in the day, eventually revealing a displaced fracture of the left femoral neck. The resident was not transferred to the hospital until after the abnormal x-ray results were obtained. Interviews with staff indicated confusion and lack of timely communication regarding the fall and the resident's condition. The unit manager and DON both stated they were not promptly notified of the incident, and an LPN expressed concern about the delay in assessment and intervention, noting that the resident was visibly in pain and her hip appeared abnormal. The delay in response and transfer to the hospital resulted in the resident remaining in pain for an extended period before receiving appropriate medical care.