A resident who was alert and who did not normally try to get up by himself was discovered on the floor by his bed. The air mattress that was on his bed was not inflated properly. It may have been uncomfortable and the underlying reason that the resident tried to get up by himself. When the nurse aides found the resident on the floor, instead of alerting the nurse and waiting for assistance, the aides returned him to his bed.
After the nurse was alerted, the resident was examined to determine if he was injured. It was noticed that he had bruising on his head and around one of his eyes. The nurse started neuro-checks on the resident, and he was transferred to the hospital for evaluation. The resident’s family and physician were also notified. While the resident was at the hospital, an x-ray of his spine indicated that he had sustained a fracture to his T1 vertebrae.
The resident was returned to the nursing home for follow-up care which included monitoring every shift for pain. An audit of the resident’s blood pressure readings was done to determine if there were any indications that might show a change in the resident’s condition or relate to the resident’s attempt to get up on his own. The facility scheduled an appointment with an interventional radiologist for further treatment recommendations. Therapy was to be involved if the resident began to show any evidence of a decline in his condition.
Before the resident was returned to the facility, the resident’s room and its surrounding environment were evaluated. There was an air mattress on the bed, but it was not inflated to the correct setting making it underinflated. That was corrected and will be monitored regularly to ensure it remains inflated properly. There was also a fall mat on the floor next to the bed.
The nurse aides who failed to follow appropriate procedure by putting the resident back into bed before summoning the nurse were disciplined and re-educated about the proper procedure to follow.
Education and Performance Improvement involved training for all staff on responding to resident falls and injuries. Staff were also educated regarding the importance of frequent checking and maintaining the correct air mattress inflation setting for residents with air mattresses.
