Description of Event or Problem · 0
PATIENT HAD BEEN IDENTIFIED AS HIGH RISK FOR PRESSURE INJURY DUE TO COMPLEX MEDICAL HISTORY. TO PREVENT SKIN BREAKDOWN, AN EHOB WAFFLE MATTRESS WAS PLACED ON TOP OF THE HOSPITAL MATTRESS. DURING HER SLEEP, THE PATIENT ATTEMPTED TO REPOSITION HERSELF IN THE BED AND WAS ABLE TO ROLL OVER THE SIDE RAILS. SHE LANDED ON THE FLOOR ON HER RIGHT SIDE WHICH RESULTED IN AN IMPACTED NONDISPLACED SUBCAPITAL FRACTURE OF THE PROXIMAL RIGHT FEMUR. THE PATIENT WAS NOT A SURGICAL CANDIDATE AND WAS TRANSITIONED TO COMFORT CARE. SHE DIED ON (B)(6) 2024. CAUSE OF DEATH: SEVERE PROTEIN CALORIE MALNUTRITION SECONDARY TO DEMENTIA, COMPLICATED BY RIGHT FEMUR FRACTURE. A THOROUGH EVENT REVIEW WAS COMPLETED. IT WAS DETERMINED THAT THE HEIGHT OF THE WAFFLE MATTRESS CONTRIBUTED TO THE FALL. THERAPY DATES: (B)(6) 2024.