Golfport Rehabilitation Center Fails to Protect Resident at High Risk for Falls

Golfport Rehabilitation Center was cited after the facility failed to ensure a resident was “provided with interventions and supervision after a fall that resulted in a fracture.” The resident was known to be at “high risk” for falls. The right side of her body was particularly weak, as she had suffered a stroke.

The surveyor of this citation conducted an observation of the facility to investigate the repeated falls. During the observation, a resident was seen sitting in her wheelchair, her left leg extended out on a leg rest. The leg was wrapped in a white elastic dressing from the knee to the foot. When the surveyor asked what happened to her leg, she smiled and said, “I fell out of bed and broke it.”

The investigator then called the resident’s daughter, who expressed concern about her mother’s safety in the facility. According to the daughter, her mother had fallen twice already from her bed. The first fall resulted in a fracture to her mother’s tibia and fibula. The daughter stated, “I was there last week, and they still haven’t provided a mat for the floor next to the bedside. They told me it takes two weeks to get a mat for the side of the bed and that they have to order it.” During her visit, the daughter also looked for a side rail that would help prevent her mother from falling. She said, “They told me they have to have a doctors order for a side rail.”

The daughter continued to discuss how she had spoken with a nursing assistant about getting a side rail to prevent falls from the right side of her bed. The facility was aware that ever since the resident had a stroke, her right side had become weaker. The assistant told the daughter that “they don’t have any side rails at the facility.” If she wanted side rails, her mother “would have to be moved to a different facility” because “ the State of Florida said they can’t have them.”

The investigator interviewed the Director of Nursing (DON) in response to the incident. The DON stated that the facility has a process for residents who fall. “Our normal process is their talked about in the morning meetings. We will document it on the event reporting what was the outcome and what was initiated.”

The DON reviewed the event logs that documented the resident’s two falls. As she read the files, she stated that after the resident returned to the facility with a fractured tibia and fibula, the plan was to put the bed in a lower position and provide mats on the floor. These interventions would help prevent further falls and injuries. Upon reviewing the logs, however, the investigator discovered there was no documentation regarding the plan to put the bed in a lower position. The DON addressed the second fall, stating “I could not find any new interventions that were put in place… after each fall you’re supposed to have a new intervention and I could not find anything.”

The investigator asked the DON about the daughter’s request for side rails. She said, “We normally don’t get rails… after a fall we have therapy assess to make sure something is in place, so she doesn’t fall out of the bed again.”

When residents experience falls in nursing homes, careful plans need to be made in order to ensure future falls are prevented. These plans, or interventions, must be documented in a care plan so all staff members know how to protect each resident. In many cases, these interventions include providing fall mats or additional equipment that will help a resident move around their room.

After speaking with the DON, the investigator returned to the resident’s room. The resident was sleeping in her bed; her head and upper torso were on the edge of the right side of the bed, which was at a 35 to 35-degree angle. According to the citation, “the bed was elevated up off the floor thus indicating it was not in its lowest position.” The blue fall mat was folded up and positioned up against a feeding tube machine.

The investigator spoke with a CNA in charge of the resident’s care that morning. She stated she didn’t know who removed the mat or left the bed in that position. Because the care plan didn’t reflect that the bed was to be in a low position, any staff member could have left the resident in a vulnerable position.

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