Failure to Recognize and Respond to Acute Change in Condition After Fall
Penalty
Summary
A resident with a complex medical history, including atrial fibrillation on anticoagulation therapy, recent pulmonary embolism, traumatic brain injury, hemiplegia, and previous subdural hematoma, experienced an unwitnessed fall from bed. Following the fall, the resident was assessed and found to have no visible injuries, and neurological checks were initiated. The resident reported not hitting his head, and his neurological status and vital signs were documented as within normal limits for the remainder of the shift and into the following day. On the morning after the fall, staff observed that the resident was hard to arouse, nonverbal, unresponsive, and lethargic, which was a significant change from his baseline. Multiple staff members, including nurse aides and therapy staff, noted the resident's altered mental status and reported it to nursing staff. Despite these observations, the response was limited to obtaining orders for bloodwork, urinalysis, and a chest x-ray later in the afternoon, rather than immediate evaluation or transfer to a higher level of care. The resident's condition continued to deteriorate, with ongoing lethargy and unresponsiveness noted by various staff members throughout the day and night. It was not until the following morning, when the resident's family arrived and insisted on hospital transfer, that the resident was sent to the emergency department. Upon arrival, the resident was diagnosed with a large left subdural hematoma with midline shift and was transitioned to hospice care, passing away several days later. The facility failed to recognize the severity of the resident's acute change in condition after the fall and did not promptly notify a medical provider or arrange for timely transfer to a higher level of care, despite clear signs of neurological decline.
Removal Plan
- The DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall to ensure timely recognition and response occurred if the resident experienced a change in condition.
- The DON and Unit Managers reviewed all residents with changes in condition to ensure immediate notification to the Medical Provider occurred.
- The Administrator, Director of Nursing (DON), President of Risk and Quality Assurance (VPRQA), Nurse Consultant, PA and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to recognize the severity of a change in condition for Resident #1.
- The Director of Risk and Quality Assurance, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the change in condition and fall policy. No changes were made.
- The Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention policies. Education includes recognizing the severity of a change in condition status post fall to include post fall assessment changes, changes in level of consciousness, and altered mental status away from baseline. Upon licensed nurse's assessment recognizing the severity of the residents change in condition away from baseline post fall, the Medical Provider will be immediately notified.