State Findings:
Based on record review, interviews and review of facility policies titled Occurrences, Lippincott Procedures – Fall Management, and SBAR Communication, the facility failed to notify the Responsible Party and the Physician of a fall for one of nine residents ((R) #4) resulting in a delay in treatment of [REDACTED].#4 fell on [DATE] and suffered a right femur/[MEDICAL CONDITION] resulting in hospitalization on [DATE] and surgical intervention on 4/8/2020.
Review of Nurse’s Notes dated 4/4/2020 at 10:15 a.m., signed by Licensed Practical Nurse (LPN) JJ, revealed the resident’s family member called and stated that the resident broke her leg. Resident is moving all extremities but states it hurts. The resident, per the family member, had surgery on that leg. Wing nurse (Registered Nurse (RN) AA) notified to give her pain medication. This nurse called the family member and advised her pain mediation will be given.
Review of an Event Report dated 4/6/2020 at 10:52 a.m., by LPN NN, revealed R#4 is complaining of pain in the right upper leg, resident unable to work with therapy due to pain. NP OO notified, new order for X-ray to right hip, femur, and knee.
Review of an Event Report dated 4/7/2020 at 4:27 a.m., by RN LL, resident still complaining (c/o) pain in her right thigh area when touched, called X-ray to upgrade order to STAT (immediately) Order at 12:00 a.m. (Midnight). X-ray done around 1:30 a.m.
Review of the 24 Hour Shift Report sheets for 4/2/2020 through 4/7/2020 revealed there was no documentation of the resident having a fall on 4/4/2020 or evidence of a fall during this time frame.
Review of an Event Summary-Safety Events, dated 4/8/2020, by the (former) DHS RN BB revealed RN AA stated to the DHS (former) RN BB that R#4 was found in the floor beside her bed on 4/4/2020 at 9:30 a.m. RN AA assessed the resident and stated the resident did not have any deformity or injury noted and was helped back to bed by RN AA. RN AA then gave R#4 a pain medication, that she was prescribed. RN AA stated that R#4 remained stable throughout her shift. The former DHS (RN BB) notified the Physician, family of the fall today, 4/7/2020.
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Personal Note from NHA-Advocates
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