Delayed Post-Fall Medical Response and Missed Wound Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medical follow-up after a fall with injury and to complete wound care as ordered. One resident with multiple diagnoses including ovarian and abdominal lining cancer, dementia, gait difficulty, and osteoarthritis experienced an unwitnessed fall in her room in the early morning hours. A CNA discovered the resident on the floor around 4:45 A.M. in a dark room, with blood on her face and two pools of blood on the floor, after tripping over the resident’s wheelchair. An LPN cleaned the resident’s facial wounds, assessed her, and administered 650 mg of Tylenol for facial pain at 4:51 A.M., with the effectiveness documented as unknown. Despite the resident having a large hematoma on her forehead, bruising under both eyes, and a laceration to her upper lip exposing her teeth, the physician was not contacted until approximately 6:45 A.M., about two hours after the fall. The physician then ordered transfer to the emergency room, and EMS was called around 7:00 A.M., with the resident arriving at the emergency room at 7:23 A.M. EMS documentation noted that facility staff reported the fall had occurred approximately two hours before the 911 call, and the resident reported a pain score of nine out of ten upon arrival at the destination. The delay in notifying the physician and arranging emergency transport occurred even though the resident had significant visible injuries and ongoing pain. A second deficiency involved failure to follow physician orders for wound dressing changes. Another resident, cognitively intact and requiring partial/moderate assistance for personal hygiene, had scattered scabbing on both legs and developed two skin tears on the right knee after a fall. The physician ordered the right knee skin tears to be cleansed with normal saline, patted dry, covered with a non-adherent dressing, and wrapped daily and as needed until healed. On observation of wound care several days later, the dressing on the right knee was dated two days prior, and the wound nurse practitioner and the resident both confirmed that the dressing had not been changed the previous day. Review of the Treatment Administration Record showed documentation consistent with the earlier dressing date, indicating the daily dressing change order had not been carried out as written.
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