What critical steps were missed during Mrs. B.’s initial admission to the hospital, and how might these omissions have contributed to her subsequent falls?

The Quality at the Bedside

Case Scenario:
Mrs. B. was an 85-year-old woman who went to a local hospital by ambulance after complaining of abdominal pain. The admissions assessment revealed that while at home, she got up at night to go to the bathroom and fell. She sustained some bruising on her hip and chipped a tooth. The Medical history revealed that she had mild colitis, gastroesophageal reflux disease (GERD), and high blood pressure. The hospital decided to admit the patient because of the high blood pressure. The nurses did not do a fall risk assessment, and fall prevention was not part of her care plan.
On the first night of admission, Mrs. B got up to use the bathroom and fell. The nurse who witnessed this filled out an incident report and gave it to the nursing supervisor. The supervisor countersigned the report and recorded the incident in the daily nursing office log. She also sent a copy to the Risk Management department. However, no one conducted any investigation or revised her care plan.
The next morning, Mrs. B. got up again to use the bathroom and fell again. She was found by a floor nurse but was not unconscious. The nurse got additional help and placed Mrs. B. back in her bed, but a complete medical evaluation was not conducted. Later that afternoon, Mrs. B. died of a massive brain hemorrhage.

Assignment Instructions

Read each question thoroughly and compose a response that is at least 150 words for each question.

• Question#1: What critical steps were missed during Mrs. B.\’s initial admission to the hospital, and how might these omissions have contributed to her subsequent falls?
• Question#2: Identify the potential legal and ethical issues involved in the hospital staff\’s failure to conduct a fall risk assessment and revise Mrs. B.’s care plan after her first fall.
• Question#3: Evaluate the actions taken by the nurse and nursing supervisor after Mrs. B.\’s first fall. What additional steps should have been taken, and how might these have impacted the outcome?
• Question#4: Discuss the role of the Risk Management department in this case. What actions should Risk Management have taken after receiving the incident report, and how could these actions have potentially prevented the second fall and Mrs. B.\’s death?
• Question#5: Considering the outcome of this case, propose a plan for improving fall prevention protocols in healthcare settings. What specific strategies would you recommend to ensure that similar incidents are prevented in the future?