Deceased resident’s family learns the facility failed to inform them of numerous falls (24) occurring over a 12-month period, and that the facility had ignored their concerns and the physician’s orders regarding the resident’s high risk for falls. The facility may have violated the False Claims Act by accepting payment for substandard quality of care.
Healthcare Compliance Perspective – Falls:
The Compliance Officer together with the DON and the Administrator must review the facility’s policies and procedures to ensure that protocols are in place to prevent fraudulent billing from federal, state and insurance benefit providers. Procedures should include the steps to be taken to report and to prevent potential violations of the False Claims Act for providing substandard care based on F684 Quality of Care. Staff must receive ongoing instruction to ensure their understanding of the federal and state regulations and that all alleged violations must be reported and investigated to prevent and correct alleged violations. Staff must also be trained regarding the absolute implementation of a physician’s orders and prescriptions for medications and care of residents, and of the requirements to keep responsible family members/guardians advised of changes and events involving residents. Audits will be conducted on a periodic basis to verify that all physicians’ orders are in place and being followed.
After experiencing 21 unwitnessed falls and three witnessed falls over a 12-month period, a resident with Parkinson’s disease in an upscale California assisted living facility succumbe
d five weeks later due to injuries he received in the last fall—fractures to his skull and nasal bone and a brain bleed.
The resident’s doctor had prescribed that alarms be placed on his wheelchair and on his bed to alert staff when he was up and vulnerable to falling. The resident’s wife and step-son had for many months repeatedly reminded and requested that the alarms be put in place. After each request, the wife and step-son were assured it was being done immediately, and each time the requests were ignored. The last request was made by the step-son when he was visiting. He talked to the director of the care unit his step-father was on and was told the staff were working on installing the alarms for immediate use. Just four hours later, the family were notified that the resident had fallen was injured and had been taken to the hospital. Five weeks later, the resident died from the injuries he received.
The family was quite angry when they learned exactly how many times the resident had fallen and that the facility had only advised them of two or three falls. They filed a complaint and the California Department of Social Services (CDSS) investigated and determined that the facility had “failed to provide proper and necessary care and supervision, resulting in numerous falls and subsequent injuries.” The CDSS penalized the facility $10,000.
During the time the resident was under in the facility, a long-term care insurance policy paid $4,000 per month and the resident’s family paid an additional $4,000 per month for his care. During the 12-month period that the facility failed to implement the doctor’s prescription for alarms to be installed, ignored the doctor’s warning about the resident’s risk for falling and failed to notify the resident’s family about all of the falls the resident experienced, the facility received $96,000 to provide the quality of care that federal law requires from a long-term healthcare provider.
