Resident Fall and Hip Fracture After LPN Activates Air Horn in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent a fall for one resident. The resident had dementia associated with other diseases, Alzheimer’s disease with mood disturbance, depression, severe cognitive impairment (BIMS of 99), and daily wandering. The resident’s care plan, last dated in October 2025 with no revision date, included interventions such as PT referral as needed, monitoring for condition changes that may warrant increased supervision, referral to restorative programs as needed, evaluation of psychotropic medications, encouraging non-skid footwear, and use of low beds with fall mats. At the time of the incident, the resident was ambulating in the hallway with a CNA and was known to walk quickly. On the date of the incident, multiple staff reported that an LPN activated an air horn (also described as a foghorn) on the hall while the resident was ambulating. One CNA stated she witnessed the LPN blowing the air horn behind the resident as the resident walked down the hall, which startled the resident and caused her to walk faster despite the CNA’s repeated instructions to slow down, and the resident fell before the CNA could reach her. Another LPN reported hearing the air horn at the nurses’ station and then observing the resident moving past at a fast pace. The LPN who blew the air horn acknowledged activating it, stating it was intended to startle other staff, and reported that after the CNA released the resident’s hand, the resident continued down the hallway and fell over lifting equipment positioned in the hallway. Staff accounts indicated that the air horn was being blown throughout the day and that it was used to scare other staff members on more than one occasion. Following the fall, staff observed a bruise on the resident’s right hip during care and notified the LPN, who assessed the resident. The resident’s family was informed of the fall and initially declined ER transport, and the facility reported that the resident appeared to be acting like herself with stable vital signs and a head hematoma. Later, when the resident was unable to bear weight on the right lower extremity and complained of pain, she was transported to the ER. Hospital records documented that the resident had sustained an acute comminuted intertrochanteric fracture of the right femur, along with a large head hematoma and an acute UTI, and she underwent operative fixation with right hip cephalomedullary nail placement and reduction before being discharged back to the facility.
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