Failure to Notify Physician After Unwitnessed Fall and New Acute Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an unwitnessed fall and subsequent acute right hip pain for a cognitively impaired resident, resulting in delayed medical care for a right hip fracture. The resident had a severely impaired cognitive status per a recent MDS and was unable to provide information about the fall. On the evening shift, a CNA found the resident on the floor next to her bed in a sitting position and notified the assigned RN. The RN assessed the resident, assisted in lifting her back to bed by carrying her under the arms with the CNA, determined she had not sustained an injury, and did not document the fall in the EMR or notify the physician of the incident. On the following overnight and day shifts, multiple staff members observed new, acute right leg/hip pain and functional decline without being aware of the prior unwitnessed fall. The overnight agency RN administered acetaminophen for pain but had not been informed of any incident. The agency CNA on that shift was also unaware of any fall and assisted the resident with pivot transfers based on prior instructions that she required only minimal assistance. The next morning, a CNA noted that the resident, who previously required minimal to partial assistance, now required extensive assistance, guarded her right lower extremity, and was unable to bear weight. This CNA reported her concerns to the agency RN and then to the oncoming RN, but was instructed to continue routine care, and subsequently observed the resident vocalizing pain during transfers to dialysis and therapy. Throughout that day, the dialysis RN and the occupational therapist were informed of the resident’s acute right leg pain and observed her vocalizing pain, screaming, and holding her right lower extremity when it was moved, yet neither had been notified of any recent fall. The OT documented that the resident verbalized pain, was unable to grade it, and screamed while holding her right lower extremity during movement. The day-shift RN, who had not been told of the fall, reported the resident’s right hip pain to the physician and obtained an order for a routine, not STAT, hip x-ray, which was completed later that evening. The radiology report, reviewed remotely that night, showed a subcapital fracture of the right femoral neck. The physician later stated she had not been notified of the fall or the acute pain at the time of the incident and that, had she been informed, she would have further assessed the resident and ordered STAT testing or hospital transfer sooner. The facility’s policy required immediate physician notification of accidents with potential for requiring physician intervention and significant changes in condition, but the RN on the evening of the fall did not follow this policy.
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