The IDPH has issued a citation to Tower Hill Nursing Home in Elgin, following a broken hip injury sustained by one resident. The injurious fall is the most recent in a series of falls that the resident had suffered, which could have been prevented had the care plan been updated and adhered to.
Nursing Home Care Planning and Fall Risk
It is standard procedure at nursing homes to revisit a resident’s care plan once the resident suffers a falling incident. This is because “a fall begets more falls,” meaning that if a resident falls once, it is a sign that they are at higher risk of falling again. One fall should trigger a revision of their care plan to determine what measures should be implemented to reduce the risk of subsequent falls.
However, this particular resident at Tower Hill was not protected by appropriate preventive measures, even after she experienced three falling incidents leading up to her injury.
Patient Suffered Several Falls
The first fall was an unwitnessed incident in her room. Her care plan was actually updated after this, referring her to physical therapy. However, for some reason, this was not carried out.
She fell again five weeks later, also unwitnessed in her room. This time, she was referred to physical therapy, but was discharged quickly because her dementia prevented her from participating in a meaningful way.
The physical therapy clinic instead recommended that she be supervised. She was found to require contact guard assist, which meant that an aide should physically put hands on her to help steady her movements. The clinic also recommended restorative care for her ambulation or walking about.
These recommendations were not incorporated into her care plan.
Two months later, the resident fell again in an unwitnessed incident, and this time, she broke her hip. She had to be sent to the hospital to undergo surgery.
Care Plan Diligence is Crucial for Injury Prevention
This injury might have been avoided if significant updates to the patient’s care plan were implemented and followed through.
Any long-term care facility should have recognized that a resident with her profile needed aggressive fall preventive measures. She had balance issues, mobility issues, dementia, and a previous diagnosis of traumatic brain injury. She also now had a history of falls that the nursing home was well aware of.
The contact guard assist that was recommended after her second fall would have helped to keep her steady and might have prevented her third and injurious fall. There are also other strategies to prevent such incidents. One is to place the resident in common areas where the staff can supervise her. The nursing home could also implement frequent rounding, or having somebody check on the resident at regular intervals, perhaps every 15 minutes.
The fact that she was not protected by relevant anti-fall measures points to substandard care.
Contact an Illinois Nursing Home Lawyer for Legal Support
Falls are a major consideration in the long-term care industry. At the very minimum, nursing homes are supposed to have explicit care plans for this particular issue, plus vigilant reassessments and meticulous implementation of these plans.
Without these, it’s a matter of good luck rather than good care that a resident doesn’t suffer serious injuries. And residents’ safety should not be left to luck.
We believe that most nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable results. Order our FREE report, Built to Fail, to learn more about why.
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