Malpractice Case Studies

Senior Care: Inadequate Fall Prevention Assessment Alleged in Death of Senior Care Patient

Written by ProAssurance Risk Management | July 2025
Allegation

Plaintiff’s family alleged failure to appropriately assess fall risk, implement fall interventions, and treatment plan resulting in three falls, fractured hip requiring surgery, and ultimate death.

Case Details

A 79 YOF with a history of dementia, hypothyroidism, mitral valve prolapse, and multiple falls was admitted to a long-term care facility. Upon admission, she required limited supervision and assistance with transfers and ambulation. Her initial Morse Fall Scale (MFS) categorized her as low to moderate risk for falls (score: 20–25). Over a four-month period, the resident experienced four documented falls. The first three falls did not result in major injuries, yet her fall risk assessment and care plan remained unchanged. Staff documented no additional interventions to address mobility concerns, such as increased supervision, assistive devices, or therapy.

Following her fourth fall, she sustained a hip fracture that required surgical intervention. Prior to this incident, she had not received any physical therapy to address her increasing mobility challenges. Post surgery, she returned to the facility with significant functional decline, including total dependence on staff for transfers and the use of a mechanical lift. However, her care plan was not immediately updated to reflect these changes. Two weeks after the fall and return to the facility, documentation reflected total dependence for transfers and an inability to ambulate but her MFS was not re-evaluated and remained unchanged. The resident’s overall health declined, marked by multiple urinary tract infections (UTIs), poor hygiene management, increased frailty, and reduced ability to care for herself.

Approximately four months after her return to the facility, the resident exhibited altered mental status, decreased oral intake, and signs of systemic decline. She was admitted to the hospital, and diagnosed with acute kidney injury, dehydration, and a UTI caused by E. coli. Despite medical intervention, her condition continued to deteriorate. Three weeks later, the resident passed away. Her death certificate cited progressive decline as the primary contributing factor leading to her death.

Expert Testimony

A board-certified orthopedic surgeon reviewed the resident’s hip fracture and subsequent health decline. His testimony focused on the impact of the unwitnessed fall at the facility, which resulted in the need for a bipolar hip arthroplasty.

While acknowledging that the resident had several comorbidities, including advanced dementia, the expert opined that her condition deteriorated far more rapidly after the hip fracture. The trauma from the fracture triggered a significant functional and cognitive decline, accelerating her loss of mobility, independence, and overall health stability. He emphasized that the fall was a critical event that initiated a cascade of complications leading to dehydration, infections, and eventual systemic failure. He concluded that—had the fall been prevented—the resident likely would not have experienced such a rapid decline and premature death.

According to the nurse expert witness, the evidence strongly suggested that the resident should have been assessed at a higher fall risk upon admission. Furthermore, after each fall, the care plan should have been updated to reflect her increasing risk with modification to her care. The failure to reassess and modify her care plan left her vulnerable to further falls and injuries. The expert also highlighted the absence of physical therapy prior to the hip fracture despite clear indications that the resident was at risk for mobility decline. She noted that nursing documentation was sporadic and insufficient to support that the resident had received appropriate fall prevention care. The expert identified several gaps in fall prevention measures such as no documented use of bed or chair alarms, no increase in resident safety checks, and no standby assistance for ambulation and transfers.

The nurse expert witness also raised concerns about facility staffing levels, questioning if there were enough staff to provide necessary supervision. She concluded that the resident’s hip fracture could have been prevented with increased supervision and staffing support. She opined that the resident should not have been allowed to ambulate independently given her level of dependence; continuous standby assistance at all times would likely have prevented the fall.

Resolution

The case settled due to lack of documentation related to fall risk assessment, gait training, placement of appropriate alarms and call lights, and safety protocols to prevent falls.

Risk Reduction Strategies

By implementing these strategies, facilities can reduce fall related injuries and improve resident safety and quality of care.

  • Educate residents and families about fall risks and safety measures.
  • Train staff on fall prevention protocols and proper transfer techniques.
  • Conduct fall assessments using a validated fall risk assessment tool upon admission, after each fall, and with any significant change in condition to ensure accurate risk identification.
  • Implement fall prevention measures such as bed and chair alarms, adequate lighting, grab bars, and non-slip flooring to minimize environmental hazards.
  • Prioritize appropriate supervision, including standby assistance for transfers and ambulation based on fall risk assessments.
  • Ensure comprehensive fall prevention documentation, including detailed care plan updates, staff rounding frequency, interventions, and physician notification.

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