Failure to Implement Fall Risk Interventions for Resident with Hypotension
Penalty
Summary
Facility staff failed to implement necessary interventions to reduce the risk of falls for a resident who was identified as high risk upon admission. The resident had multiple diagnoses, including atrial fibrillation and hypertension, and was admitted with low blood pressure. Upon admission, the resident was wearing a yellow bracelet indicating fall risk, and the initial blood pressure reading was significantly below the facility's defined threshold for hypotension. Despite these indicators, there was no documentation that the resident's physician was notified of the low blood pressure, nor were additional interventions implemented to address the increased fall risk. On the day of the incident, the resident's Fall Risk Evaluation score was 13, confirming high risk status, and the resident required moderate to substantial assistance for mobility and toileting. Later that evening, the resident attempted to use a urinal located on the right side of the bed and slid off the bed onto the floor. At the time of the fall, the resident's blood pressure remained critically low, and subsequent monitoring showed persistently low readings. The resident reported occasional dizziness and spinning sensations when turning, although did not recall feeling dizzy immediately before the fall. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the resident's fall risk and low blood pressure, but acknowledged that the physician was not notified and that monitoring and interventions were not initiated prior to the fall. Review of facility policies indicated that hypotension and fall risk should prompt evaluation and communication with the physician, but these steps were not documented or carried out in this case.