Question

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.
Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?
in one paragraph with references

Answer 1

• The adverse event in this case is Ms. Reid's fall after surgery, which resulted in a sudden change in her mobility from ambulatory to requiring assistance.
• The cause is post-surgical weakness and potential gait instability, exacerbated by the environment (bathroom at night) and lack of appropriate mobility support.

What factors supported this?

Pre-existing vulnerability: Ms. Reid, although somewhat self-sufficient, was likely already experiencing age-related frailty and decreased balance, making her more susceptible to falls.

Post-surgical effects: Surgical procedures, even minor ones, can cause muscle weakness, pain, and fatigue, further impacting gait and balance.

Inadequate support: The lack of documented change in Ms. Reid's status despite her fall suggests a potential failure to identify and address her increased vulnerability post-surgery. This could include inadequate mobility assessments, insufficient assistance during transfers, or lack of environmental modifications.

References:

Institute for Healthcare Improvement (IHI): "Preventing Falls with Injury in Ambulatory Care"

Centers for Medicare & Medicaid Services (CMS): "Guidance on Falls Prevention in Nursing Homes"

American Academy of Orthopaedic Surgeons (AAOS): "Falls Prevention: A Guide for Older Adults"