On November 23, 2011, a resident fell while attempting to walk to the bathroom, unassisted, despite requiring stand-by assistance.  While backing herself into the toilet, she became tangled up in her oxygen tubing, fell forward, and hit her head on her roommate’s footboard.  She suffered hip pain, which worsened during the day.  She was sent to the emergency department and a hip fracture was confirmed.  The incident was observed by a housekeeper.

Even though she was at high risk for falls due to her dementia, severely impaired cognition and her unsteady gait, the resident did not have a pressure sensitive alarm on her bed, which would have sounded and notified the staff that she was getting out of bed.  Moreover, the use of an alarm had not been included on her fall care plan.

The staff did not apply a pressure sensitive alarm to her bed until the day after she was readmitted to the facility, following surgical repair of her left hip fracture.

Iron Co Medical Care Facility was cited by the state of Michigan for failing to completely implement a fall prevention plan of care.  In addition, the facility was cited by the state for failing to ensure that the resident received adequate supervision to prevent accidents.