IDPH has cited and fined Aperion of Spring Valley nursing home after a resident there died due to brain bleed which resulted from a fall while left unattended in the bathroom.
The resident at issue was receiving care at the nursing home after having a hip replacement done. She was considered a fall risk and her care plan called for following facility fall protocols. Her Minimum Data Set, which reports to the federal government the level of assistance that each resident requires, indicated that the resident was not steady and required assistance of staff when moving from seated to standing position, walking, turning around, moving off and on the toilet, and with surface-to-surface transfers. The facility policies stated that residents who require assistance will not be left alone to bathe, shower, or toilet. As part of her medication regimen, she was receiving two anticoagulant (“blood thinner”) medications which can increase the risk of a brain bleed or other uncontrolled bleeding after a fall.
On the day of this nursing home fall, the resident was brought to the bathroom by an aide. On the way to the bathroom, the resident reported feeling unsteady, but said that she was okay after arriving there. The aide positioned her standing in front of the toilet with her walker in front of her and then left the bathroom to clear away her roommate’s dinner tray and to give the resident some privacy. After being left alone in the bathroom, the resident reached for the door handle and tripped on the walker, falling to the ground and hitting her head. The aide got the nurse who did a brief assessment of the resident and applied steri-strips to control the bleeding. However, the bleeding would not stop (likely due to the blood thinners) and the resident was sent to the hospital.
At the hospital, a CT scan was done which showed that there were multiple areas of hemorrhage in the brain with a midline shift. There were also multiple facial fractures. Based on the results of the CT scan, she was intubated and transferred to a regional trauma center. A neurosurgical consult was obtained, but the surgeon indicated that if she survived surgery, she would not make a meaningful recovery. The family elected for comfort measures only because the resident had always indicated that would not want heroic measures. She was extubated and died several hours later. Her death certificate indicated cause of death was subdural hematoma and subarachnoid hemorrhage from a fall.
There are a couple of obvious issues with the care that this resident received. First, her care plan was inadequate in that all it called for was following facility protocols. A well-done care plan calls for specific steps that must be taken for each resident and must be communicated to the staff charged with her care. This resident was at high risk for falls due to her unsteadiness on her feet and was assessed as needing help with getting off and on the toilet but was left alone in the bathroom. Because she was on blood thinner medications, any fall that this resident experienced had a high risk of resulting in catastrophic injury, including the kind of brain bleed she in fact experienced. The aide involved told the state surveyor that she did not know that the resident could not be left alone. The facility failed both the aide and the resident by not putting the aide in a position to deliver the care that the resident truly needed.
There was also a violation of the facility policies which required that residents who required assistance with toileting not be left alone. The aide did not know that this resident could not be left alone which indicates that she did not know what the facility policies required. Not knowing what the facility policies are is an indicator of poor training which is especially problematic when care plans are reduced to “following facility protocols” rather than spelling out a detailed set of steps which must be taken. Poor training failed both the resident and this aide.
Sadly, poor training is consistent with the way that most for-profit nursing homes are run because training is an investment in the staff which costs the nursing home money. 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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