Failure to Prevent Falls and Address Clinical Risks Resulting in Resident Death
Penalty
Summary
The facility failed to effectively assess, implement, monitor, and modify interventions to prevent falls and address accident hazards for a resident admitted for short-term rehabilitation following multiple fractures. Upon admission, the facility did not implement several critical physician orders, including antibiotics, sliding scale insulin, lidocaine patches, and Seroquel, due to incomplete review of the hospital discharge summary. This resulted in the resident experiencing multiple episodes of hyperglycemia, recurring UTIs, and withdrawal from antipsychotic medication, all of which increased the risk of falls and behavioral disturbances. The resident's care plan and fall risk assessment contained inaccuracies and omissions, failing to address significant diagnoses such as narcolepsy with cataplexy, osteoporosis, and the use of multiple high-risk medications. Despite the resident exhibiting hallucinations, anxiety, wandering, and self-transferring behaviors, the care plan was not updated to include appropriate safety interventions or increased supervision. After a fall resulting in a subdural hematoma and foot fracture, the care plan was minimally revised, and the resident continued to self-ambulate without adequate interventions to mitigate further risk. Subsequent to the initial fall and injury, the resident experienced additional adverse events, including another fall, choking, and worsening of the subdural hematoma, ultimately leading to death. The facility did not recognize or report the medication errors in accordance with policy, nor did it conduct a thorough review of the discharge paperwork to identify all missed orders. The death certificate listed the manner of death as an accident due to complications from acute on chronic subdural hemorrhage resulting from falls.