Failure to Report Fall Results in Delayed Fracture Diagnosis and Treatment
Penalty
Summary
Certified Nursing Assistant 1 (CNA 1) failed to immediately report a fall incident involving a resident with Alzheimer's Dementia, who had moderately impaired decision-making abilities and memory problems. During an episode in the shower room, the resident began to fall, grabbed a metal bar, and lowered himself to the floor, resulting in yelling, kicking, and swinging his arms. CNA 1 and another staff member observed a skin tear and scratch on the resident's left arm after the incident and informed the Licensed Nurse (LN 1) only of the injuries, not the fall itself. LN 1, believing the wounds to be superficial and unaware of the fall, did not conduct a change of condition assessment at that time, as required by facility policy. This lack of immediate and complete communication led to a two-day delay in diagnosing a left arm fracture, as the resident continued to display pain and swelling before an X-ray was ordered and the fracture was identified. The facility's policies required prompt reporting of incidents and changes in condition, as well as immediate assessment and notification of the physician and family in the event of an accident. The failure to follow these protocols resulted in a delay in appropriate treatment and pain management for the resident.