IDPH has cited and fined Casey Healthcare nursing home after a resident there fractured a hip in a fall after the nursing home failed to follow the resident care plan.
The resident care plan is the framework for how most routine care get delivered in a nursing home. There are six parts to it: (1) assessment – threats to the health and well-being of the resident are assessed, (2) care plan – a series of steps or interventions are developed which are intended to address those risks and are assigned to various categories of staff members, (3) communication – the care plan in communicated to the staff charged with carrying it out, (4) implementation – it is carried out on a day-to-day, shift-to-shift basis, (5) evaluation – the care plan is evaluated on an ongoing basis to see if it is effective and meets the care needs of the resident, and (6) revision – if the care plan proves ineffective in practice or the care needs of the resident change, it must be revised.
The resident at issue had been assessed as being a fall risk. Part of the fall prevention care plan which was put in place called for the use of a personal alarm (a form of bed alarm) when the resident was in bed or in a chair and to check the function and position of it each shift. On the day of the accident, staff heard yelling coming from the resident’s room. When they responded, they found both of the resident at issue and her roommate on the floor. The roommate had fallen and the resident went to help her, with the net result being that both ended up on the floor. The resident had rotation and shortening of the leg on assessment – signs of an apparent hip fracture. She was brought to the hospital where this was confirmed.
As part of the investigation into this nursing home fall, it was discovered that the personal alarm was not in use at all. This was a violation of the care plan, and more importantly, it represented a lost opportunity to prevent this fall. Had the alarm been in place and operating, when the resident got up to help her roommate, the alarm would have sounded. This would have served to remind the resident that she should not be up, while at the same time alerting the staff that she was up unattended. Given the length of time that it would have taken for her to get up from her own chair to get to where she was found on top of her roommate, the sounding of the alarm would have given the staff enough time to respond to prevent the fall.
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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