Failure to Immediately Notify Physician After Resident Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify and consult with a resident’s physician after a significant change in condition following a fall. The resident was an elderly female with unsteadiness on her feet, muscle weakness, osteoporosis, and severe cognitive impairment (BIMS score of 3). Her MDS indicated she required substantial/maximal assistance for transfers, used a wheelchair for mobility, and had daily use of chair and bed alarms. Her care plan identified her as high risk for falls related to gait and balance problems, with an intervention to follow the facility’s fall protocol. On the date of the incident, an RN heard a voice at approximately 4:50 a.m. and found the resident on the floor in the corner of her bedroom, seated on her left hip with her head and left shoulder propped against the wall. Neurological checks were initiated and were within normal limits at that time. The resident had a knot and scrape on her left forehead, complained of pain to the left side of her head and left foot, and rated her pain as 7. The RN cleansed the wound, left it open to air, administered PRN hydrocodone for pain, and notified administration at approximately 5:10 a.m. and the responsible party at 7:01 a.m., but did not notify the physician of the fall or the injury at the time of the incident, despite knowing about the after-hours on-call system. Later that day, an LVN documented that the resident continued to complain of severe head pain and left lower extremity pain with range of motion. The resident requested transfer to the emergency room, and the responsible party agreed. At that time, the resident’s neurological status had changed, with generalized weakness, slow eye opening, and weak grips. Before transfer, the LVN used the after-hours on-call system to notify the on-call MD, who ordered the transfer to the emergency room. Imaging (CT of the head and x-ray of the lower foot and ankle) was negative. The facility’s Incident/Accident Reporting policy required that family and physician be notified for all incidents “no matter how insignificant,” and the resident’s physician stated he expected immediate notification if there was an injury and that failing to notify him immediately could result in delay of care. The facility’s fall policy did not include steps for notifying the MD after a fall.
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