A Tennessee nursing home has been ordered to pay over $500,000 to the family of a woman who suffered a fatal fall at the facility in early 2019. The resident, who had dementia and used a wheelchair, was found on the floor of her locked room. The resident was transferred to a local hospital and was diagnosed with a traumatic brain injury. She was transferred back to the nursing home under hospice care and died five days later.
The resident was found lying on the floor at approximately 7:30 p.m., and there is no evidence that she had been checked on since 2 p.m. The complaint stated that the motion sensor alarm had been disabled, and that she had not been checked on for several hours by the staff of the nursing home. During the investigation, the caregiver that was assigned to the resident gave conflicting statements about what happened on the day of the fall, and other healthcare workers would not sign the investigation reports because they thought the statements were fabricated or contained false information. Two whistleblowers, who worked at the nursing home, came forward to explain what really happened on the day that the resident fell. The arbitrator of this case wrote in his report that there was plenty of testimony indicating a cover-up and retaliation against employees who questioned or expressed concerns about what happened.
In addition, the nursing home never told the family at the time of the fall what really happened. It was not until the two whistleblowers came forward to explain that the family became aware of wrongdoing on the part of the nursing home.
The arbitrator wrote in his report, “The fall was predictable, foreseeable, and preventable.”
Issue
Failure to follow facilities’ protocols for patient safety can result in injuries to a resident. This may be considered provision of substandard quality care and result in an immediate jeopardy citation, including fines. Also, retaliation cannot be tolerated in a workplace, and any instances should be reported immediately.
Discussion Points
- Review policies and procedures for patient safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also, review all retaliation policies to ensure that they are current and up to date. Document the trainings and keep a signed copy in the employee’s education files.
- Train all appropriate staff on patient safety policies and procedures. Train staff on what is retaliation and what they should do if they think they have been a victim of retaliation.
- Periodically audit care plans to ensure that they are appropriate and contain evidence-based interventions to keep residents free from injury. Periodically discuss retaliation with staff and ask if they have been a victim.
