An Iowa nursing home resident died after a nine-hour delay in receiving medical care for multiple serious injuries she sustained in a fall. State inspection reports indicate that on June 2, 2023, at 9:45 p.m., a nurse aide found the resident on the floor of her room complaining of pain “all over.” The aide told inspectors that there was so much blood that she began wiping the resident’s hands with a washcloth in an effort to find the source.
According to the inspection report, facility staff checked the woman’s neurological signs, then gave her a shower and put her to bed without giving her any pain medication. A worker at the facility told inspectors they had given the woman a shower “because there was so much blood they couldn’t find where it was coming from.”
At 6:30 a.m. the next day, the facility contacted the resident’s power of attorney (POA) and transported the resident to a hospital emergency room. Emergency room staff noted the resident’s right leg was shortened and rotated outward, and that she had a head laceration with dried blood above her right eye. A series of X-rays revealed a displaced fracture of the right arm, as well as a fractured leg and hip. The resident was then transferred to a larger hospital for a higher level of care, but she died on June 12, ten days after she fell.
The resident’s POA said that when she asked a nurse why they had waited until the next day to send the resident to the hospital, she was told that they hadn’t wanted to call her in the middle of the night to ask permission. She said she asked the nurse when 9:30 p.m. was considered the middle of the night, but the nurse didn’t answer her.
The resident’s physician said that a review of the call logs revealed that there was no call for the resident’s fall, and he did not remember receiving one. He said he found a fax dated June 2, 2023, at 10:45 p.m., that documented the resident was found on the floor on her right side, her range of motion and neuro’s were normal, she had a hematoma, and complained of pain all over. He commented that looking at the fax, the staff should have called 911.
The Iowa Department of Inspections, Appeals, and Licensing has proposed fines against the facility for failing to provide appropriate pain management ($9,000), failing to assess and address a resident’s altered condition ($9,000), and failing to ensure residents remain free of neglect or abuse ($8,000).
Compliance Perspective
Issue
F689 states that the resident environment must remain as free of accident hazards as possible, and each resident should receive adequate supervision and assistance devices to prevent accidents. The requirement includes identifying and evaluating hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. If a fall occurs, the resident must be assessed thoroughly, and the plan of care updated to reduce the likelihood of future falls. The physician should be notified promptly of all falls, and if a change in condition occurs, the physician must be notified immediately. Failure to prevent falls can be considered provision of substandard quality care, and may result in an immediate jeopardy citations, fines, and lawsuits.
Discussion Points
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting and documenting incidents/accidents to ensure they include current requirements.
- Establish a stop, look, listen care plan for residents at risk of falls. This means that any staff person passing the room should look into the room, listen for problems as they pass, even if it is not someone on their assignment that day and the resident has not called for assistance. Train all appropriate staff on resident safety policies and procedures, documentation, and reporting requirements. Access falls-related training information here. Document that the trainings occurred, and file the signed documents in each employee’s education file.
- Conduct a falls risk analysis for each resident at the time of admission, quarterly with the care plan cycle, and as needed, and implement individualized interventions starting on the day of admission. Periodically audit care plans to ensure that they are appropriate and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes. Audit your incident/accident reports to ensure that the responsible party and physician were notified of events appropriately, that all issues where reporting is required were managed timely with appropriate follow-up, and that documentation is complete.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
