Miller Health Care Center in Kankakee, Illinois Cited After Resident Suffers Two Fall-Related Fractures With Ordered Alarm Missing
The Illinois Department of Health has cited and fined Miller Health Care Center in Kankakee, Illinois when a resident with a physician-ordered bed and chair alarm suffered two falls resulting in major injury after investigators found the alarm was repeatedly missing or not in use. State investigators determined the facility failed to keep in place the fall-prevention interventions that had been ordered by the resident’s physician, consented to by a family member, and written into his care plan.
The resident, a 76-year-old man, had diagnoses including Parkinson’s disease, dementia with behavioral disturbance, chronic congestive heart failure, urinary tract infections, tremors, and abnormalities of gait and mobility, along with muscle weakness, unsteadiness on his feet, a history of repeated falls, a prior right hip fracture, and an artificial hip joint placed before his admission. According to a family member, he was admitted to the facility for rehabilitation. His admission fall risk assessment identified him as at risk for falls, and his care plan, initiated the following day, identified him as high risk for falls related to deconditioning and balance problems, with an intervention calling for a bed and chair alarm to be in place as needed. A physician’s order for the bed and chair alarm was active from the day of his admission, and a consent for its use was on file.
In the first fall, the resident fell in the bathroom one evening while attempting to transfer without assistance. He was assessed with an abrasion to his elbow and a skin tear at the base of his thumb, with a small amount of blood found on the floor. During the following shift he began complaining of pain in his right leg and was sent to the hospital, where he was diagnosed with an acute fracture of his right femur. The facility’s own fall incident report noted that his motion alarm was not present on the bed at the time. A certified nursing assistant’s statement indicates she had last seen him in bed shortly before the fall, and that he used his bathroom call light minutes later, after which he was found on the bathroom floor. Days after this fall, the resident’s physician order was updated to specify that the alarm be applied whenever he was in his bed or chair.
In a second fall, the resident was found lying on the floor in front of his recliner after attempting to transfer himself to his wheelchair for dinner. He reported increased pain in his right leg and was sent to the hospital, where he was diagnosed with a displacement fracture involving his existing hip replacement. A certified nursing assistant’s statement indicates that when she arrived to take him to dinner, she found him on the floor near the bathroom door, and that his chair alarm had not been turned on.
The resident was hospitalized and underwent an orthopedic surgical procedure. Hospital records reviewed by investigators indicate he reported the second fall occurred as he was returning to bed after using the bathroom on his own. Records show he was later readmitted to the facility with a surgical dressing on his right thigh.
During the state’s on-site survey, investigators observed the resident on three consecutive days. On the first day, he was in his wheelchair wearing a fall-risk bracelet, with large, dark bruises on his arm and the back of his hand. On the second day, he was asleep in bed with no alarm attached; his alarm was sitting on a chair next to the bed. On the third day, he was again asleep in bed with no alarm attached; his alarm was instead attached to his wheelchair, which he was not using.
A family member who said she visits the resident daily stated he has had multiple falls since his admission, and that she had signed consent for the bed and chair alarms when he was admitted. She stated that after each fall, it was determined that the facility had not had the bed alarm or chair alarm in place. She said that on the day she was interviewed, she arrived to find his alarm sitting on a chair near his bed while he sat in his wheelchair on the other side of the room without the alarm attached, and that he had bandages on both legs, one elbow, his shoulder, and a finger.
The facility’s medical director stated that a bed and chair alarm should be implemented once ordered, and said that while anyone who falls can sustain a fracture, it is a concern when an ordered alarm intervention is not in place, as was the case with this resident. A nurse practitioner confirmed the resident’s femur fracture resulted from the first fall and that the second fall further injured his existing hip replacement, requiring surgery, and stated his bed and chair alarm should be on at all times. The facility’s restorative nurse, who has served as its fall coordinator, stated the resident had an active order for the alarm to be connected any time he was in bed or in his chair, that the alarm sounds as soon as pressure is relieved from the pad, and that the sound should give staff time to intervene depending on their proximity. She said staff are expected to round hallways throughout their shifts, and identified the resident as high risk for falls due to his Parkinson’s disease, gait abnormality, weakness, unsteadiness, low blood pressure, and frequent attempts to transfer himself. She said his point-of-care prevention tasks included the bed and chair alarm, bladder prompting every two hours, and hourly safety checks, and confirmed that a fall risk score above 10 indicates a resident is high risk. She also stated that fall interventions are generally expected to begin within 24 hours of a resident’s fall risk assessment, and that she personally initiates related point-of-care tasks, including bed and chair alarms, within 24 hours of a resident’s admission, or by the following Monday for weekend admissions.
The facility’s written fall-prevention policy states that residents at high risk for falls will be placed on fall risk precautions, with an interdisciplinary team initiating a protocol of interventions. Its personal body alarm policy states that nursing staff are to check the placement and proper working order of a resident’s alarm each shift.
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