Failure to Address Hypotension and Medication Needs in Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's medical diagnosis and medication regimen were incorporated into preventive interventions to avoid falls and accidents. Specifically, the care plan and fall interventions did not address the resident's diagnosis of hypotension or the prescribed medication, Midodrine, which was to be administered when the resident's systolic blood pressure dropped below 95 mm/Hg. Documentation showed that there were days when the resident's blood pressure was below this threshold, but the medication was not administered as ordered. The care plan prior to the fall only included teaching on positioning and instructions for assistance, with no reference to the resident's hypotension or related interventions. The resident, who had a history of hypotension, abnormal gait, lack of coordination, and muscle wasting, experienced a fall resulting in a forehead laceration requiring sutures and a laceration to the left arm. At the time of the fall, the resident's blood pressure was recorded at 85/63 mm/Hg, which was significantly lower than their baseline. The fall occurred when the resident attempted to pick something up from the floor after getting up from bed. Staff interviews revealed that the fall care plan and assessments did not consistently consider the resident's medical conditions or medication regimen, and there was confusion among staff regarding responsibility for fall assessments and care plan updates. Further, the facility's policy required fall risk assessments upon admission, readmission, quarterly, significant change, and annually, with interventions to be reevaluated and revised as necessary. However, the Falls Coordinator stated that quarterly assessments were not performed and that interventions were only added after a fall occurred. There was also a lack of communication and coordination between the restorative nurses and the Falls Coordinator regarding fall assessments and care planning. The failure to address the resident's hypotensive state and medication needs in the care plan and to utilize fall assessments contributed to the resident's fall and subsequent injuries.