Resident Waits Hours to be Sent to Emergency Room

FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, hospital emergency room record, and review of the facility’s falls policy it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #6) received adequate supervision and assistance to prevent accidents. Resident #6 had an amputation of the right great toe on 12/04/15 and returned to the facility the same day. The facility failed to assess the resident’s need for assistance with ambulation and develop a care plan to address the risks related to the amputation of the toe. As a result, Resident #6 ambulated to the bathroom without assistance and sustained a fall with injury fracturing the right humerus and the right hip on 12/04/15.

Record review revealed Resident #6 was found on the floor of his/her bathroom at 11:20 PM on 12/04/15. The resident was assessed to have an abrasion to the right eyebrow and a raised area to the forehead and no other injuries. There was no documented evidence the physician was immediately notified of the fall. Further review revealed staff assisted the resident back to bed. The resident had complaints of right arm pain and was given Tylenol (pain medication) on 12/05/15 at 12:20 AM, and again at 4:45 AM.

Record review revealed the physician was not notified of the fall until 12/05/15 at 10:00 AM. According to the record, the resident continued to complain of pain and the physician was contacted again at 1:30 PM on 12/05/15 and ordered x-rays that revealed a fracture to the right humerus. Orders were received for the resident to have a sling/immobilizer and follow up with an orthopedic physician. According to nurse’s notes, pain flow sheets, dietary intake record, and the resident’s care flow record, Resident #6 continued to have pain and declined in eating and drinking and activities of daily living. On 12/09/15 at 5:30 PM, the resident’s family requested the resident be sent to the hospital for evaluation and treatment.

Interview with the Director of Nursing (DON) on 01/12/16 at 4:00 PM revealed if the resident had a fall, the resident should have been assessed at the time of the fall, the physician and family contacted, and if the resident had injuries requiring treatment the resident should have been transferred to the hospital. The DON further stated if the resident had no injuries at the time of the fall, the resident was to be monitored for 72 hours for any further complications, and the physician notified of any changes of condition. According to the DON, when a resident returned from the hospital after a procedure, the resident was to be assessed and the resident’s care plan updated with any interventions the resident would require related to the assessment.

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

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RESIDENT WAITS HOURS TO BE SENT TO THE EMERGENCY ROOM