Resident Set for Discharge Falls and Sustains Fracture: Regrets Not Requesting Assistance
A resident was scheduled for discharge to an assistive living setting the day after completing her skilled nursing facility rehabilitation. Prior to her admission to the nursing home, she fell at home and sustained a fracture requiring surgical repair. During her last night at the facility, she got out of bed and walked to the bathroom, closed the door, lost her balance, and fell. Her roommate was awakened by the noise of her fall and used the call bell to summon help. Staff responded quickly but were unable to move her due to her severe pain. EMTs transported her to the hospital via an ambulance, and she was admitted with a fractured pelvis. The resident may have thought that she was able to do more than she could because she was going to be discharged the next day, and this sense of being independent culminated in a fall and fracture.
The resident’s stay at the facility was complicated by a urinary tract infection that required a previous hospitalization. After falling, she was upset with herself for not calling for help to go to the bathroom. Her bed was not in the lowest position to enable her to more easily get in and out. She had bilateral anti-skid strips on both sides of her bed as her son had requested, and a fall care plan that included activities was completed when she was admitted. The administrator met with the resident’s son. He explained that he had planned for his mother to go to an assisted living facility when she was discharged but indicated that now she will return to the nursing home for more rehabilitation. The resident’s care plan was updated to indicate the need for re-evaluation when she returns. The family previously expressed concerned about the resident’s incontinence and indicated she had been continent when at home. At the time of the fall, staff was toileting her every two hours, and she wore a pull-up brief. During the day, she rang her call bell frequently, and staff were very attentive to her needs. It was noted that she did not normally get up at night. Her medications included Lasix, with alternating doses of 20 mg. to 40 mg. Her last dose was at 9 am the day before the fall. A grievance form was filled out previously related to delirium the resident experienced from her anesthesia. The medical director stated that for individuals over age 85, there is a 1 in 2 chance of delirium occurring from anesthesia. The resident’s previous fall at home possibly indicated beginning decline, and the family may have experienced denial regarding this change. The facility filed a report with the Department of Public Health.
