An 82 year old female resident with partial paralysis, muscle weakness, and cognitive impairments fell from her bed on 7/17/19 and sustained significant injuries that put her in a persistent vegetative state. The resident had a high risk for falls and was supposed to receive special precautions to prevent her from rolling out of her bed. Nonetheless, her bed was not lowered on 7/17 and she fell due to a “slippery mattress” while receiving care. The resident was being cared for by one nursing assistant despite requiring two-person assists.

After the fall, the resident was vomiting and bleeding and a nurse practitioner ordered she be sent to the hospital. The nurse on duty did not believe the situation was an emergency however and called a non-emergency transportation service. The resident was therefore not sent to the hospital until three hours after her fall. The resident suffered skull and cervical fractures and severe cerebral hemorrhaging and required neck surgery, a tracheostomy, and a ventilator for breathing. Eventually, the resident’s life support treatment was terminated and she died on 9/5/19. The facility was cited for numerous failures, including failing to follow the resident’s care plan, failure to have adequate staffing, and failure to attend to the resident after her fall.

Download the pdf of this citation HERE.

Violation of the Month Archive