Failure to Follow Care Plan and Therapy Restrictions Leads to Fatal Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall and follow the resident’s care plan and therapy-to-nursing instructions, resulting in a major injury. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma. An MDS assessment showed intact cognition but documented lower extremity impairment on one side and a need for substantial/maximal assistance for bed mobility and sit-to-stand, and dependence for toilet transfers and walking 10 feet. Therapy evaluations and progress notes documented poor strength and balance, generalized weakness, dizziness, lightheadedness, episodes of hypotension, and a need for maximal assistance of two staff for transfers, sit-to-stand, and ambulation. Therapy-to-nursing communication and the care plan specified that ambulation with a rolling walker was to occur in therapy only, that transfers required two-person substantial/maximal assistance with a sit-to-stand lift, and that toilet transfers required substantial/maximal assistance. Despite these documented needs, on the morning of the fall the resident’s call light was answered by a CNA who assisted the resident out of bed and ambulated him to the bathroom using only a walker and grippy socks, without a gait belt or sit-to-stand lift, and without a second staff member. The CNA reported that she did not check the Kardex for the resident’s required level of assistance because she had taken care of him before and did not think to check, even though she was aware that the Kardex should be used to determine assistance levels. While the resident was standing and the CNA turned away to open the bathroom door, she heard a loud sound and turned back to find the resident on the floor on his back and initially unresponsive. The incident report and nursing notes documented that the resident fell flat on his back while transferring to the bathroom, went unconscious, and was later noted to be lethargic with nonreactive pupils and a high PAINAD score indicating significant pain behaviors. Clinical records and interviews further showed that nursing staff were not consistently aware of or following the resident’s documented risks and limitations. Physical therapy notes recorded very low blood pressure readings in standing and sitting, and the nurse practitioner documented generalized weakness, gait instability, dizziness, and lightheadedness, with orthostatic vital signs later confirming significant blood pressure changes with position. A floor nurse who had previously cared for the resident stated that he walked with two staff and a walker and needed more assistance getting off the toilet, but the nurse on duty at the time of the fall believed the resident was a one-person assist and was unaware of recent dizziness or low blood pressure. The DON confirmed that the care plan and Kardex required two-person assistance, sit-to-stand lift for transfers, and ambulation with therapy only, and that the resident had been ambulated by nursing staff contrary to these directives. The fall resulted in multiple skull fractures, subdural hematoma, brain compression, and was listed on the death certificate as complications of blunt force head trauma from a fall in the nursing home.
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