IDPH has cited and fined AHVA Care of Stickney nursing home after a resident there suffered a fractured hip in a fall.
One of the focuses of care in the long-term care industry is fall prevention. Many residents in nursing homes are at risk for significant injuries due to falls, and many studies have confirmed that fall injuries have significant negative impacts on the quality of life for nursing home residents. Additionally, some types of injuries, in particular fractured hips, are strongly associated with increased mortality.
Because of all of this, one of the regular assessments that is done is of a resident’s fall risk. Nursing homes use a variety of standardized tools to assess fall risk, but two of the main factors in just about every fall risk assessment are: (1) some form of musculoskeletal weakness or gait or balance dysfunction and (2) some type of mental or cognitive issue – intermittent or constant confusion, dementia, poor safety awareness, or impulsive behaviors. The reason that the mental/cognitive aspect feeds into a resident’s fall risk is that when one or more f these issues is present, the resident cannot be counted on to follow instructions or make good decisions regarding his/her own safety.
When a resident is considered to be a fall risk, a fall prevention care plan must be created. This is a series of steps which must be taken on a day-to-day, shift-to-shift basis which are intended to reduce the resident’s risk of falls. Two of the main stays of fall prevention are keeping the resident under observation by the staff, frequent rounding, and keeping the resident’s environment free and clear or tripping or slipping hazards.
The resident at issue was one who was considered at risk for falls. She was known to have intermittent confusion with impulsiveness and poor safety awareness. Further her Minimum Data Set (MDS) indicated the resident was not steady and could only stabilize with staff assistance while walking and rising from a seated position.
On the day of this nursing home fall, an aide entered the resident’s room and found the resident sitting on the other bed her room. When the resident was asked what she was doing there, she reported that she had gotten up to throw something in the garbage can and had tripped over the cord to her roommate’s oxygen concentrator machine.
The resident’s physician was notified of the fall and a portable x-ray was ordered of the pelvis. However, the results of the x-ray were inconclusive for fracture of the left hip. Rather than report the inconclusive results back to the doctor to see what needed to be done, no one contacted the doctor for three days during which the resident complained of hip pain. The resident was eventually sent to the hospital where a CT scan showed a comminuted (broken in more than two pieces) fracture of the femur, extending into the femoral neck (the bridge of bone extending from the thigh bone into the hip).
There were a number of shortcomings in the care that this resident received. Inadequate supervision and failing to round on the resident led to her getting up without the assistance she required and her falling over an obvious tripping hazard (the cord to the medical equipment). Past that the resident was subjected to additional unnecessary pain as her fractured hip went untreated for three days due to the failure of the staff to report the inconclusive results of the x-ray back to the doctor.
One of our core beliefs is that 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 result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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