IDPH cited and fined Bria of Palos Hills nursing home after a resident was rolled out of bed during care and suffered a brain injury. Compounding the neglect on the part of the staff, they failed to timely summon EMS to take the resident to the hospital.
The resident suffered from a variety of conditions, including hemiplegia (weakness on one side of the body), dementia, and generalized weakness. She was known to have poor trunk control which means that she had great difficulty controlling her body. She required two person assist for activities of daily living which includes incontinence care and was dependent on staff for all aspects of care.
This nursing home fall occurred while the resident was getting care with only one aide, not the two that was required. The aide reportedly looked away and the resident rolled out of bed, landing on the floor. A nurse was brought into the room, noted a hematoma near the eye and bleeding from the nostrils. A lift was brought into the room and she was returned to bed. The doctor was paged and the family was notified. The family requested that the staff call 911 to have the resident brought to the hospital.
The fall occurred at approximately 7 pm, but the paramedics were not called until 9:25 pm. There was no documentation of what care the resident received during the interim period of time. When they arrived, no one was available to let them in through the door that the nursing home had designated for paramedics. They waited 5 minutes before someone let them into the nursing home. When they got to the resident, there was no nurse available to brief them and the aides were unable to tell them what happened. They were told by the family that the resident had fallen and was placed back to bed by the staff. The paramedics saw that the resident was bleeding from the mouth and that there was blood on the floor.
They brought the resident to the hospital where a CT scan showed an acute subdural hematoma with a midline shift. She was transferred to a higher level of care. The citation from IDPH did not describe what the final outcome for the resident was, but those kind of findings in a resident with as many pre-existing medical problems is obviously grim.
There are a number of issues that are readily apparent in this situation.
First, the underlying accident is one which should not have happened. The resident required assist of two for what was being done at the time she fell from bed, but there was only one aide in the room at the time. This is a resident who was at high risk for falling from bed due to the combination of dementia, hemiplegia, generalized weakness, and poor trunk control. Once her momentum began to carry her toward the edge of the bed, she was not likely to stop moving in that direction. The fact that a single aide was working with her at the time is an indicator that understaffing is likely an issue at this facility. In all likelihood, the care plan was not being followed.
Second, once a resident falls, a 72-hour fall watch is customary with frequent neuro checks to monitor for signs of a brain bleed. This resident clearly suffered one, but the chart did not contain any documentation of these checks having been done. The fact that there was still blood on the floor some two and a half hours later makes me wonder what was being done during that almost two and a half hour window. Did anyone check on the resident?
Third, when the paramedics arrived at the facility, not only was no one there to bring them to the resident, they could not get inside. And once they did, there was no one to provide them with the crucial information they needed to properly care for the resident.
This is a case where failures abounded and were ultimately visited on the resident.
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Other blog posts of interest:
Two serious falls at Holy Family Villa
Resident rolled from bed by staff at Generations at Applewood
Brain bleed from fall at Heritage Healthcare in Bloomington
No fall prevention care planning at South Suburban Rehab
Improper transfer leads to broken leg at Springs at Monarch Landing in Naperville
Resident rolled from bed at Village at Victory Lakes
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