Healthcare Compliance Perspective – Fall Risk:
CMS regulation F689 Accidents requires each facility to provide an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions, monitoring for effectiveness, and modifying interventions when necessary. Additionally, the facility staff are responsible to communicate the risks and interventions to all relevant staff, assign responsibility, provide training as needed, document interventions correctly, and ensure that the interventions are put into action.
The family of a deceased resident of a nursing home in Syracuse, New York, contends that their 73-year-old mother did not receive the quality and type of care her physician prescribed for her lung condition. When the resident was admitted in 2015, she was to always have her head elevated and receive oxygen 24-hours-a-day. Instead, shortly after being admitted, her daughter visited and found her mother lying on her back with her oxygen tank empty.
The resident’s physician reported that he had indicated that the resident was at great risk for falling, and the resident’s daughter stated she also informed the facility administrator of her mother’s high fall risk. Due to an error by the facility staff, the woman’s fall risk was miscalculated, and she was not provided with any fall prevention measures, such as an alarm pad that would alert staff if she was attempting to get out of bed. Consequently, less than 24-hours after being admitted, the resident fell and fractured her hip and wrist. Four weeks later she died, and her injury from the fall was reported to have been a contributing factor in her death.
The resident’s fall risk calculation omitted 12 points from the form’s first page, which would have calculated the risk number as 19 instead of 7, indicating a high risk of falling. A calculation of 12 is the risk point that indicates the need to use preventative measures like alarm pads and a cushioned pad on the floor next to the bed.
The resident’s children filed a complaint with the State of New York and recently received a call from the New York State Department of Health informing them that their mother’s case was being re-opened.
The home’s administrator reported they are working to improve conditions at the nursing home. They have added 66 additional staff and have also contracted with a person to provide staff training on how to provide better quality and compassionate care to the residents. The administrator also reported that a recent annual state inspection showed that the facility is improving.
