IDPH has cited and fined Macomb Post Acute Care Center after a resident there died from complications of a fall.
The resident in question fell when trying to stand from her recliner and reaching for her walker. The resident fell forward, hitting her head on the nearby bedside table. She sustained two lacerations to her scalp requiring sutures – one 7 cm laceration and one 3 cm vertical laceration between her eyebrows. She also suffered a Grade 3 odontoid fracture which required cervical fusion surgery of C1-C2. She complained of neck pain and pain in her right hip where she had previous surgery.
The resident was transported to the local hospital emergency department then airlifted to a trauma center for subsequent surgery. Unfortunately, the resident’s condition deteriorated and she was moved to the ICU. The resident then passed away, approximately 11 days after the fall. Her death certificate lists pneumonia, the odontoid fracture, and ground level fall as causes of death.
The facility failed this resident in several critical ways. First, the resident’s care plan was woefully deficient. It only included two areas of concern – code status and activity preferences. For a resident deemed high fall risk taking medications that increase falls, having recent surgery, and requiring assistance to transfer, much more should have been documented. Her care plan lacked any details about:
– Fall risk level
– Required supervision or assistive devices for transfers
– Current medications and associated fall risks
– Details of recent physical therapy for her femur fracture
– Cognition status
– ADL assistance needs
Additionally, the facility did not establish appropriate fall interventions for the resident despite her high fall risk. Her unaddressed anxiety on the morning of the fall may have contributed to the incident.
While assistive devices were provided, the level of supervision the resident needed was unclear in her record. Progress notes document her functional ability in conflicting ways. Appropriate supervision and assistance were likely not in place when she attempted to transfer and subsequently fell.
Finally, the resident’s recent hip surgery and spouse’s death two days prior were red flags that should have heightened vigilance. However, the facility still failed to prevent this disastrous fall. Insufficient staffing and procedures likely played a role.
In summary, the facility severely failed the resident by not comprehensively assessing and planning for her fall risk, supervision needs, and emotional/psychological factors. This resulted in an injurious fall with ultimately fatal consequences. More thorough assessment, care planning, supervision, and fall prevention could have protected the resident’s well-being.
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