Failure to Notify Physician of Resident’s Post-Fall Knee Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to follow its "Changes in Resident Condition" policy by not notifying the physician when a resident reported altered knee sensation after a witnessed fall. The resident, who had diagnoses including paraplegia, a stage 4 sacral pressure ulcer, and osteomyelitis, was cognitively intact and required assistance with mobility. On the date of the fall, an SBAR documented that the resident experienced an unavoidable witnessed fall during a transfer, slipping from a CNA’s grasp and striking the left foot on the wheelchair footrest. An order was obtained for X‑rays of the left foot, second toe, and bilateral hips/pelvis, but no knee X‑ray was ordered at that time. In the days following the fall, the resident and family reported symptoms involving the knees that were not promptly communicated to the physician. The family member stated that when visiting about two days after the fall, the resident’s knees were very swollen, and the resident reported hearing a crack at the time of the fall and feeling a hot burning sensation in the knees for two days. The family member reported that when asking a nurse about X‑rays, the nurse said X‑rays had been done on the back and foot, and the family member then requested staff to contact the physician for a knee X‑ray. The resident stated that he landed on both knees, heard a crack, and that about an hour after the fall his right leg became swollen and warm, and by the next morning he felt a burning sensation in his legs, which he reported to two CNAs and an LVN. Staff interviews and record review confirmed that the physician was not notified of the resident’s new knee symptoms as required by policy. CNAs described seeing the resident with both knees on the floor and feet under the wheelchair, and one CNA observed redness of the upper shins after the fall. An LVN who worked the day after the fall stated the resident reported his knees did not feel normal and did not want his legs moved; the LVN reviewed the orders, saw an existing X‑ray order for the foot and hips/pelvis, and assumed it covered the whole leg. The LVN acknowledged that there was no specific knee X‑ray order and that she should have messaged the physician about the resident’s knee complaints. The DON stated that licensed nurses were required to assess and notify the physician of changes in condition, including when the resident reported burning sensations in the knees, and that the facility’s policy required notifying the resident, physician, and representative when an accident results in injury and has potential to require physician intervention.
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