An Iowa nursing home where a resident was found dead “in a puddle of blood” after a series of falls has been fined $18,000 by the state. According to a report from the Iowa Department of Inspections and Appeals (DIA), on June 11, 2021, staff found a female resident lying on her right side on the floor beside the lower end of her bed, face down in a puddle of blood. Her right eye was swollen, with a laceration, and there was a laceration on her right upper lip. The nurse couldn’t find vital signs on assessment.
According to inspectors, during the preceding two months, the resident had fallen eight times. On April 7 she had fallen and broken her arm. On April 12, she had fallen and injured her head and hip and was found on the floor with a large amount of blood under her head.
The facility was cited for having failed to report the April 12 head injury to the DIA. The DON told the inspectors that it hadn’t been reported because the ER physician had said that the brain bleed which was found on April 12 could have occurred with the fall on April 7.
The DON also told inspectors that due to the staffing crisis during COVID, the facility had difficulty getting staff and did not have enough staff to do restorative nursing programs.
The facility was cited for eleven federal violations, including deficiencies related to comprehensive care plans, overall quality of care, pressure sores, resident records, immunizations, the reporting of alleged violations, and the accuracy of resident assessments. The state fined the facility $18,000 for violations related to environmental hazards, medication, and treatment.
The inspection was triggered by four complaints, three of which were substantiated, and three facility-reported incidents, which were all substantiated.
Issue
Facilities must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Facilities also must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after discovery if the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. The administrator of the facility or the designated person on duty must be notified, as well as other officials (including local law enforcement, the State Survey Agency, and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
Discussion Points:
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting of incidents/accidents to ensure they include current requirements.
- Train all appropriate staff on resident safety policies and procedures and on reporting requirements for events with and without serious injury. Document that the trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit care plans to ensure that they are appropriate and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes. Audit your incident/accident reports to ensure that all issues where reporting is required were managed timely with appropriate follow-up.
