A resident now requires permanent use of her wheelchair after a series of falls at Spectrum Health Rehab and Nursing Center in Grand Rapids, Michigan.

When she was admitted into the facility, the staff recognized that the resident had a severe cognitive impairment (Alzheimer’s), anxiety, a history of falls from the previous year, and was considered a “high fall risk.”  Despite her condition, the resident was allowed to walk independently.  As a result, on January 8, 2012, she attempted to stand up out of her chair and fell. Despite this fall, however, care plan interventions to prevent further falls were not set in place.

On January 8, the resident fell again in the dining room and an intervention was added and the nursing staff was instructed that the resident “not be left alone in dining room.” Staff could not explain why additional fall interventions were not in place after the second fall in such a short period of time.  When the ADON (Assistant Director of Nursing) was questioned about the second fall, the reply was that the resident is independent and may go where she wants without supervision.

Then on January 12, just four days later, the resident fell again; she was found alone in her room on the floor with her head bleeding. She was sent to the emergency room and required staples in the back of her head. The resident now requires permanent use of her wheelchair as she is not able to walk on her own.

If care plan safety precautions had been added and followed at the time her risk factors were identified, the falls and confinement to the wheelchair may have been prevented.