Healthcare Compliance Perspective:
A Compliance Officer faced with multiple concerns, e.g., –quality of care, agency staffing, patient privacy-needs to ultimately address them all; but, should first determine what is most pressing and what poses the greatest risk to the residents’ quality of care. The starting point in this scenario would be to address the facility’s policies and procedures for fall risk evaluation and fall prevention and intervention followed by implementing needed changes and providing education/training for all regular, newly hired and temporary employees.
After being admitted to a Philadelphia retirement community following a stroke, a resident whose son previously was a part of the President’s Cabinet, fell five times during his four-day stay. He died about four hours after the last fall where he stumbled and hit his head. A Pennsylvania Health Department (PHA) report points to a failure in performing their “essential duties and responsibilities” by the facility’s administrator.
The report indicated that there had been no fall prevention plan developed even though the resident’s medical records showed a history of falling. The records indicate that staff also did not perform neurological checks after his fall or attempt CPR when he was found unresponsive after the last fall.
The nurse involved was from an agency that provides temporary staffing. She was arrested and charged with “involuntary manslaughter and tampering with paperwork.” She is scheduled to appear in court next week for a preliminary hearing.
After the resident’s death, the police were told in an affidavit by an assistant nursing director that she had asked the nurse if she had performed the evaluations that are required after a fall and was told by the nurse that she had and said, “They were fine.” However, the last entry on the resident’s neurological chart showed that the evaluation did not occur until 20 minutes after the resident’s death. The nursing director says that the nurse told her, “Well, I falsified that one.” About eight hours of video surveillance was reviewed by the police and indicated that the nurse had not performed a single neurological exam.
The facility’s policy requires that residents who hit their heads are supposed to have close neurological monitoring that includes “assessments every 15 minutes for the first hour and then every hour for the next three hours.
