LITTLETON, CO- LIFE CARE CENTER OF LITTLETON

Based on record review and interviews, the facility failed to prevent falls for one (#1) of two out of three sample residents.

Resident #1 was admitted to the facility on [DATE] with diagnosis and history of frequent falls and sustaining a closed head injury following a fall. The resident was at risk of falling as indicated in her plan of care.

The facility failed to implement effective fall precautions with her risk of falling. Due to the facility’s failures the resident fell on [DATE], following the fall she required hospital treatment for new injuries that included scalp laceration, subdural hematoma and fractures of the left parietal (top part of the skull) and occipital bone (back of skull).

Resident #1 was admitted on [DATE] to the facility after being treated for a recent pulmonary embolism (blood clot to the lung). The resident had a history of falling and was diagnosed with traumatic subarachnoid hemorrhage (head injury) and subdural hematoma (brain bleed) after fall on 3/18/22 while living alone in the community. The resident was treated conservatively for that head trauma.

The 5/9/22 Fall Risk Evaluation revealed the resident was at risk for falling but did not specify how significant that risk for falling was; the evaluation documented the resident had three or more falls in the last 90 days. 

A change in condition evaluation dated 5/10/22 at 6:35 p.m. revealed the resident had a fall which developed soft non-tender swelling to the back of the head. The resident had no observed change in mental status. 

An event note dated 5/10/2022 at 7:30 p.m., documented the resident’s family member came back to visit the resident the evening after the resident fell and at approximately 7:25 p.m. the resident’s family member discovered swelling to the back of Resident #1’s head. The nurse assessed the resident and the location of the swelling was found to be soft and nontender. The on-call provider was contacted. The provider gave orders for the resident to be sent to the emergency room for assessment and treatment due to the resident’s medical history of anticoagulation therapy.

A health status note dated 5/11/2022 at 4:09 a.m., documented a call was placed to the hospital emergency room for a condition status update. The resident had been admitted to the hospital with intracranial hemorrhage (bleeding inside the skull).

New nondisplaced fracture of the left parietal calvarium (top part of the skull), likely contiguous (affected by/worsened by) with the previously seen left occipital bone fracture.

The 5/11/22 Fall Investigation Report revealed Resident #1 was found on the floor on 5/10/22 at 6:45 a.m. by a staff member passing by the resident’s room due to unknown circumstances.

Resident #1 did not return to the facility following the fall and hospital admission; interventions revisions were not implemented for the resident.