04/15/2023
Case study: Failure to develop fall prevention care plan leads to fall with multiple fractures
We reached a settlement on behalf of the estate of a nursing home resident who was injured when she fell in her room and suffered a fractured femur, tibia, and fibula.
When the resident was admitted to the nursing home, she was assessed as being a fall risk. She was considered a fall risk due to gait abnormalities which required the use of a walker, intermittent confusion, incontinence, and the use of multiple medications (also called polypharmacy). Because she was properly assessed as being a fall risk, the nursing staff was required to develop a fall prevention care plan to help reduce the risk of her falling and sustaining injury. However, the care plan coordinator elected to not put a fall prevention care plan in place when her initial assessment was done. She then made the same decision two more times when the resident came up for re-evaluation. Each time the resident was re-evaluated, she was assessed as a fall risk, and in fact her risk factors increased over time.
There was no fall prevention care plan in place when the resident fell in her room while walking unattended to her closet to get a sweater. When she fell, she broke her right femur, tibia, and fibula. The femur fracture extended down far enough toward her artificial knee that it was impossible to set the fracture, so a revision knee replacement surgery was required. While undergoing physical therapy, she suffered a re-fracture of the same femur which required a second surgery.
The resident died approximately 9 months after the fall due to complications from unrelated health conditions.
