An Illinois nursing home was fined $25,000 after the Illinois Department of Public Health determined it failed to implement progressive interventions to prevent falls. The facility also failed to notify a physician and obtain treatment orders in a timely manner for a resident who had a fall.
The facility was investigated after a complaint about a resident who fell and wasn’t sent to the hospital for multiple days despite having right leg pain. The resident was diagnosed with a fractured right hip that required surgery.
According to facility documents, the resident had mobility issues and cognitive impairments. The facility fall log states that the resident fell on 6/4/21, 8/15/21, and 10/22/21. The residentās nursesā notes documented the falls. The notes did not document any interventions implemented after any of the falls. There was also no documentation in the residentās care plan that the facility implemented and documented progressive interventions to address the falls and prevent the resident from future falls.
According to the nursesā notes, on 6/4/21, the resident had a witnessed fall which resulted in a skin tear to the left hand. On 8/15/21, the resident fell while walking from room to hallway, resulting in a skin tear to the elbow. On 10/21/21, the resident attempted to stand up from a wheelchair. A nurse documented the fall and notified the DON and the physician. The next day the resident complained of pain to the right leg and arm. The physician was notified, and an x-ray was ordered. The x-ray report said the resident’s right hip showed chronic and degenerative changes and that short interval follow-up was recommended, if symptoms persisted, as a non-displaced fracture could not be excluded.
According to the nursesā notes, on 10/23/2021, the resident continued to complain about pain, but there was no documentation that the physician had been notified. When the residentās pain continued, the physician was called 10/24/21 and then again 10/25/21. The physician said the resident should be sent to the emergency room for an evaluation of the right leg. A hip fracture requiring surgery was diagnosed.
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.Ā
- Train all appropriate staff on resident safety policies and procedures, documentation, and reporting requirements. Document that the trainings occurred, and file the signed documents in each employeeās education file.Ā
- 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 all issues where reporting is required were managed timely with appropriate follow-up, and that documentation is complete.Ā
