Failure to Prevent Falls and Follow Post-Fall Protocols for High-Risk Resident
Penalty
Summary
A resident with multiple diagnoses, including muscle weakness, abnormal posture, profound intellectual disabilities, dementia, and osteoarthritis, was assessed as high risk for falls. Despite this, the facility failed to prevent multiple fall incidents for this resident. The resident experienced two unwitnessed falls, one of which resulted in a closed right hip fracture. The care plan interventions following the first fall included promoting call light use and therapy evaluation, but the root cause of the fall was not clearly identified, and the intervention did not address the actual cause, as the resident was unable to use the call light effectively due to her condition. During the second fall incident, staff found the resident on the floor next to her bed, exhibiting pain and inability to extend her right leg. The nurse performed a head-to-toe assessment and range of motion, noting facial grimacing and abnormal leg positioning. Despite the resident's nonverbal status and clear signs of injury, staff assisted in transferring her back to bed using a Hoyer lift and a blanket, contrary to facility expectations for handling suspected injuries. The resident was later sent to the hospital and diagnosed with a right hip fracture. The facility's post-fall procedures were not properly followed, as staff moved the resident before paramedics arrived, potentially exacerbating her injury. Additionally, the interventions added to the care plan after the first fall were not effective in preventing subsequent incidents, and the root cause analysis did not result in meaningful changes to the resident's environment or supervision. The lack of effective fall prevention strategies and failure to adhere to post-fall protocols contributed to the resident's repeated falls and injury.