West Bay of Tampa Fails to Care for Resident After a Fall

West Bay of Tampa has been cited by the Florida Agency for Healthcare Administration because “the facility failed to ensure interventions were implemented for one… [resident] after a fall with a major injury.” This resident had three recent falls by the time the state investigative team was able to visit the facility. After the resident’s falls, the facility did not have appropriate interventions in place to prevent falls and injury from falls.

The resident fell in November 2019 from their wheelchair. A nursing home staff member had been with the resident, but the resident tried to reposition herself in the wheelchair and slipped out of the chair. The Nursing Home Administrator said that “the fall, on 11/27/19, was witnessed by an aide, as the resident repositioned self in the wheelchair then slid out onto the floor with both feet in front of her.” In this facility, the Nursing Home Administrator was also the Risk Manager. A Nursing Home Administrator is a person responsible for the operations of a nursing home but may or may not have medical experience. A Risk Manager may be responsible for seeing risks to nursing home residents or staff and for creating plans that minimize the opportunity for harm to a resident or a staff member.

The resident fell out of her wheelchair in November 2019, suffered an unobserved fall in December 2019, and fell again in January 2019. The resident dealt with injuries from each fall, although the types of injuries were not specified for each incident. A resident falling in a nursing home is a serious issue, as the injuries from a fall can severely impact a resident’s mobility, health, and overall quality of life.

The Nursing Home Administrator also said that the resident “complained of pain to her right lower extremity and was sent to the hospital” on the day she fell. About a week later, “the resident complained of left lower extremity pain, an X-ray was obtained, and previously obtained blood work was returned as critical. The resident was sent to the hospital prior to the results of the X-ray. The X-ray at hospital and the one obtained by the facility showed a left femur fracture.”

The resident had been evaluated as someone with moderate cognitive impairment. She was visited by the state investigative team after the three recorded falls and had a trapeze above her bed. Trapezes are often used in nursing homes to give residents increased mobility and a larger range of maneuverability, or as a way to increase strength through physical therapy. The resident was not able to reach the call light, which was hanging down the side of her bed. A nursing home staff member moved the light within reach.

The Nursing Home Administrator “stated the facility had multiple interventions in place, which included a low bed and to engage the resident to assist with fidgeting with the braces and frequent clinical interventions.”

State investigators visited the facility two days later with the Nursing Home Administrator/Risk Manager and saw that the resident’s call light was within reach, but there were no fall mats on the floor. The bed was raised above knee height, which meant that the resident was at a higher risk of injury if she were to fall out of bed. Some possible interventions for residents who are at risk of a fall is to keep their bed closer to the ground and to place fall mats around the bed to protect the resident if they do fall. In this case the citation report mentioned numerous times that the resident’s “room did not have floor mats,” insinuating that the nursing home should have installed them after a series of falls.

West Bay at Tampa was cited because the facility failed to “ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.” This resident had fallen multiple times and suffered injury, resulting in her being rated as at a high risk of falling in the future. The nursing home care plan promised to provide a lower bed height and to protect the resident from future injury, but this was not the case when state investigators visited the resident on two separate occasions.

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