F0689

G

Failure to Prevent Falls and Medication Errors Related to Antihypertensives

Bellingham, Washington Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free from avoidable accident hazards and to provide adequate supervision and monitoring for a resident with a known fall risk and complex medication regimen. The resident was admitted with hypertension, chronic kidney disease, heart failure, and vision deficit, and was assessed as high risk for falls. The Care Area Assessment (CAA) identified medications as a fall risk factor and directed staff to proceed to a fall-related care plan. The care plan included a problem related to mood and behavior medications with side effects such as dizziness, drowsiness, unsteadiness, blurred vision, and orthostatic hypotension, and a separate fall risk problem related to deconditioning. Interventions focused on environmental and behavioral strategies such as call light within reach, proper footwear, keeping the room free of clutter, and having the resident sit at the edge of the bed before standing. The care plan did not include a focus area or specific interventions related to the resident’s cardiac blood pressure medications, despite the identified medication-related fall risk.

Beginning in early December, the resident experienced multiple falls. On one date, the resident fell, hit their head, underwent a neurological assessment, CT scan, and lab work, and one blood pressure medication was discontinued, but there were no new fall interventions or care plan updates. A subsequent fall occurred several days later with no new orders or care plan changes. Additional falls in early January included an event where the provider documented orthostatic hypotension with a significant drop in blood pressure upon standing and positive signs of dehydration, for which the resident received IV fluids. The resident also slid from a wheelchair and had another fall the following day, again without new orders, interventions, or care plan revisions. A pharmacist review later noted frequent falls and frequent medication order changes due to dizziness, weakness, and falls, yet the care plan was not updated to address actual falls or medication side effect monitoring.

On a mid-January date, the resident fell in their room, struck their face, and complained of back pain, later being diagnosed in the emergency department with a right forehead hematoma and an acute L2 vertebral compression fracture. The ED report documented that the resident stated they fell because of their blood pressure. Review of the Medication Administration Record (MAR) showed the resident had three blood pressure medications with parameters to hold doses if the diastolic blood pressure was below 60, but the medications were administered when the blood pressure was 112/58 on the day of the fall, and on multiple other occasions when the diastolic reading was below the ordered parameter. These administrations were later acknowledged by facility staff as medication errors that should not have occurred. The facility’s incident investigation for the mid-January fall documented no apparent injuries at the time of the incident and no injuries post-incident, left pain and level-of-consciousness sections blank, and left the predisposing factors section blank. Although the investigation stated that neurological checks were done, there was no documentation of these checks in the report or medical record, and medication risk factors previously identified in the CAA were not reviewed as part of the post-fall investigation.

Interviews further described the resident’s decline and ongoing symptoms. The resident representative reported problems and overdosing with blood pressure medications since admission, frequent falls, dehydration requiring fluids, and that the resident had become weaker and in pain, impacting their ability to participate in therapy. Nursing staff explained that the electronic medication system required entry of vital signs but did not prevent administration outside ordered parameters, and that it was the nurse’s responsibility to hold medications when indicated; they confirmed that the administrations outside parameters were errors and that the provider should have been notified. Staff also reported the resident had been sleeping more, staying in bed, and not eating breakfast. The resident described ongoing dizziness, new problems with blood pressure and blood pressure medications, a fall associated with feeling dizzy at the sink, and persistent back pain after being told they had broken their back. The resident also reported using the call light as instructed but stated it usually took at least half an hour for staff to respond. The DON acknowledged that administering blood pressure medications outside ordered parameters constituted medication errors and that these errors and medication as a contributing factor were not identified during the fall investigation.