Failure to Provide Adequate Supervision and Post-Fall Monitoring for Resident with Hemiparesis
Penalty
Summary
A resident with a history of Parkinsonism, cerebrovascular accident (CVA) resulting in left-sided hemiparesis, and a stage 4 sacral pressure ulcer required assistance for bed mobility. During morning care, a registered nurse (RN) was providing wound and incontinence care when the resident, who was positioned on the left side, rolled out of bed after the RN turned away to retrieve a brief. The resident struck their head on the wall and then the metal bed frame, resulting in an orbital floor blowout fracture with herniated extraconal fat. The care plan indicated the resident required assistance from two staff for bed mobility, but only one staff member was present at the time of the incident. There was confusion among staff regarding the care plan, with some believing the two-person assistance requirement was implemented only after the fall, despite documentation indicating it was in place prior to the incident. Following the fall, the facility did not ensure thorough post-fall monitoring or neurological checks as required by policy. The monitoring order was not consistent with the 72-hour minimum, and neurological checks were incomplete or missing for several shifts. The resident exhibited symptoms consistent with a concussion, including intermittent confusion, vomiting, and swallowing difficulties, as documented by hospice staff and family. Despite these changes in condition, there was no evidence that a physician was notified or that the care plan was updated to reflect the resident's deteriorating status. Interviews with staff and review of records revealed that the RN did not position the resident's flaccid side appropriately, contributing to the fall. The facility's investigation also found that staff were not fully aware of or did not follow the care plan interventions for bed mobility. Additionally, there was a lack of communication and documentation regarding the resident's post-fall symptoms and changes in condition, including episodes of vomiting and increased confusion. The medical examiner determined the resident's death was accidental, caused by a concussion in the setting of Parkinsonism, with the orbital fracture and CVA history as significant contributing conditions.
Removal Plan
- Reviewed, screened, and updated care plans for residents with diagnoses of hemiparesis and falls related to bed mobility.
- Met with Hospice staff to ensure effective communication regarding changes in condition. Updates should be given to the DON or designee before Hospice staff leave the building.
- Educated facility and agency staff on bed mobility, post-fall assessments, and changes in condition.
- Initiated bed mobility and change in condition competencies to ensure staff follow proper techniques and protocols. Ad hoc education to be provided immediately when indicated.