Fall precautions in rehabilitation facilities rely on a multi-layered approach combining risk assessment, environmental safety, supervised mobility, and assistive devices. Staff perform a comprehensive fall risk assessment upon admission, after any change in condition, and at regular intervals, using validated tools such as the Morse Fall Scale, STRATIFY, Hendrich II Fall Risk Model, or the Fall Risk Assessment Tool.
Nurses, physicians, physical therapists, and occupational therapists collaborate to evaluate the patient’s gait, balance, strength, and cognitive status.
When a hospital labels a patient a high fall risk and then fails to act on that label, the patient is put in danger. A fall risk score means nothing if staff do not check how the patient walks, provide a walker or other aid, watch for medication side effects, and stay with the patient during risky activities like bathing.
Without those steps, the likelihood of a fall rises sharply, and a fall can cause serious physical harm.
In this case, our client was admitted to a hospital after several falls at home, and nursing staff placed her in the “high risk for falls” category. Despite this, a nurse left her alone in the shower during a shift change and did not tell the oncoming staff where she was.
She was found on the floor more than an hour later after striking her head, and the records indicate she lost consciousness.
The Townsley Law Firm represented her and recovered a settlement of over $300,000.
The Fall Risk Was Identified. The Precautions Were Not.
When a hospital identifies a patient as a high fall risk and then fails to protect her, the breakdown is not in recognizing the danger but in responding to it.
Our client and her husband told the nursing staff on admission that she had been falling at home, including a fall in her bathroom that left bruising under her eyes. The admitting nurses noted that she needed help to walk and that her gait was unsteady. They placed her in the high-fall risk category.
The information the hospital needed to protect her existed from the very first night of her stay. The care team did not translate that information into protection.
The next morning, a nurse documented that our client “ambulates independently” with “no muscle weakness.” That entry was inaccurate, and it was copied into the record again on the following shift. No nurse, nurse practitioner, or physician ever watched her walk to see how much help she needed. She was never given a walker. An occupational therapist screened her chart and recorded “no eval at this time,” and therapy did not evaluate her until hours before discharge.
A record that does not reflect a patient’s true condition cannot produce the right care plan. Here, it gave the false impression that a high-fall-risk patient could walk safely on her own.
The danger was known. The response never came.
New Medications Raised the Risk Further
Every change in a patient’s condition or medications is supposed to trigger a fresh look at her fall risk, and that did not happen here.
The emergency physician ordered daily orthostatic blood pressure checks, which test whether a patient’s blood pressure drops when she stands. Those checks were never done.
On her second full day in the hospital, a nurse practitioner ordered two new high-dose blood pressure medications on top of the one she was already taking. By then she had already lost nearly 4,000 cc of fluid through rapid diuresis. Low blood pressure and dizziness standing are well-known risks of that combination, and they make a fall far more likely.
The medications were given late that morning. The records do not show that anyone explained the side effects to her or her husband.
Her fall risk had just gone up. Her protection did not.
A Pattern of Falls That Each Should Have Triggered More Protection
That afternoon, her nurse removed her heart monitor, covered her IV site, and placed her in the shower at about 3:30 PM. The nurse then left her there alone.
Her husband later told staff that “the last nurse” had assured him his wife would not be left alone in the shower. He said he never would have left if he had known otherwise.
At 4:34 PM, a fall alert was called. A licensed practical nurse found our client on the floor more than an hour after she was placed in the shower. That nurse wrote that the patient’s nurse had “assisted Pt to the shower and left her alone and I was not aware.” Our client had hit the left side of her head, and the records indicate she lost consciousness.
A CT scan showed soft tissue swelling along her forehead. Later entries documented a knot on her forehead, a headache, pain in her thigh, and bruising on her arms, trunk, and ribs from striking the wall and toilet.
Her husband was not told she had lost consciousness, and no neurologist was consulted.
Communication Failures Among the Care Team Made It Worse
Fall prevention is not one person’s job. It depends on nurses, nurse practitioners, physicians, and therapists sharing what they know about the patient’s risk, so that her protection keeps pace with her needs.
That communication broke down at the most dangerous moment. The nurse who left our client in the shower did not tell the oncoming staff where she was.
The record also raised serious concerns. Before the fall alert, the nurse edited her original entry to add that she “gave report.” Two minutes after the fall alert, she edited it again to add that she “informed nurse of pt being in shower.” Instead of rushing to check on her patient, she was changing the chart. Other entries, including the patient’s fall risk score, were added to the record nearly 20 hours after the fact.
After the fall, staff began reminding our client and her husband to call for help before getting up. Those safety instructions came only after she was hurt. She did not end up on the floor because she ignored safety precautions. She ended up there because the hospital failed to follow its own.
A coordinated team would have kept a high fall risk patient safe in the shower. This one did not.
