IDPH has cited and and fined Mason City Area Nursing Home after a resident there fell and suffered a fractured hip while being transferred from her bed to her wheelchair by an aide who was not using a gait belt.

Use of a gait belt is a basic fall prevention strategy.  A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers.  The gait belt allows the staff member assisting the resident help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall.  Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall.  Either places both staff and resident at risk for injury.  A gait belt is a basic piece of equipment in a nursing home and is provided by the nursing home for staff to use.  Its use is often required by the resident care plan and/or facility policies and procedures.

Here, the resident’s Minimum Data Set (MDS) specified that the resident required the assistance of one staff member for transfers, was unable to ambulate, and was unsteady when going from a seated to standing position.  The MDS is submitted under penalties of perjury to the federal government and is a statement as to the condition of the resident and the levels of care and assistance that the resident requires.  The reason that the MDS is submitted to the federal government under penalties of perjury is that the MDS forms part of the basis by which the nursing home is paid and this is the certification by the nursing home that a) this is the kind of care that the resident requires and b) that the nursing home is in fact providing it.

Here, the facility’s policies and procedures specified that when staff was providing assistance with transfers, a gait belt was required to be in use.  Taken together, the MDS and policies and procedures indicated that when this resident was being transferred, there would be physical assistance from one staff member who would be using a gait belt.

On the morning of this nursing home fall, the resident was being transferred from her bed to her wheelchair with the help of a single aide.  There was no gait belt in use, as she could not find the one in the resident’s room and someone “stole” hers.  As the resident went to turn to get into her wheelchair, her legs crossed over when she attempted to pivot.  She lost her balance and began to fall.  Had a gait belt been in use then, the aide would have had a chance to either prevent the fall or bring it under control.

However, there was no gait belt in use.  As a result, the aide was reduced to trying to bring the fall under control by grabbing at the back of the resident’s pants.  This was as ineffective as might be expected and both the resident and the aide fell to the floor.  The resident complained of immediate pain to the left hip.  She was sent to the hospital where x-rays confirmed a fractured hip.  She had to undergo surgery to repair the fractured hip.

Obviously, the most immediate cause of the fall was the failure to use the gait belt.  However, when you see staff take shortcuts in the care of a resident such as attempting a transfer without a gait belt rather than taking the time to find this necessary and required piece of equipment, it raises a question of whether the nursing home was understaffed.  Sadly, understaffing a nursing home is a feature, not a bug of the nursing home business model.  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.

Other blog posts of interest:

Resident left without gait belt fractures arm in fall at Clayberg Nursing Center

Piatt County Nursing Home resident breaks neck in fall from power recliner

Christian Nursing Home resident suffers severe leg injury in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Westmont Manor Nursing & Rehabilitation Center nursing home after a resident there suffered a brain bleed due to being rolled from bed by the staff during incontinence care.

The resident at issue had a history of having suffered a stroke with resultant left-sided weakness and cognitive deficits.  The resident’s Minimum Data Set (MDS) called for the assistance of two staff with bed mobility.

In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed.  This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.

The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives.  When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed.  When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed.   The resident care plan further called for keeping the resident’s bed in the lowest position.

On the day of this nursing home fall, the resident was receiving incontinence care from a single aide, not the two which were required per the MDS.  We have written on multiple occasions about how having one person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples), and that proved again to be the case here.  As the aide rolled the resident away from him, the bed was not in the lowest position as called for in the care plan, and the resident rolled over the edge of the bed, hitting his head on the floor.  He was brought to the emergency room where it was discovered that he had a brain bleed.

This is a simple case of the resident not receiving the call which was necessary and which the nursing home certified it was providing – it was literally a situation where you had one person doing a two-person job.

The deeper question is of course why did this aide attempt to do a two-person job by herself?  The likely answer relates to understaffing of the nursing home.

Federal regulations require that the nursing home have enough staff on hand to meet the care needs of the residents on a 24/7 basis.  Unfortunately, nursing home often fail to meet that standard because understaffing is a key component of the nursing home business model.  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.

Other blog posts of interest:

Prairie Manor resident suffers brain bleed in fall

Failure to supervise Westmont Manor resident leads to fall and broken hip

Resident at Chateau Nursing Home in Willowbrook suffers spinal fractures in wheelchair accident

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined University Rehab nursing home in Urbana after a resident there suffered a fractured hip in a fall from bed while he was receiving incontinence care.

Doing proper assessments is a basic step to assuring the safety of nursing home residents.  Two assessments which are done in well-run nursing homes are bed mobility assessments and side rail assessments.  Bed mobility refers to the ability of a nursing home resident to turn, change position, and maintain position in bed.  This is important because it helps determine the staff levels and equipment needed to provide proper care to a resident while they are in bed.  It is one of the assessments recorded in the Minimum Data Set (MDS) for a resident.  Side rails carry some risk of injury or entrapment, and the side rail assessment is used to determine whether the use of a side rail as an aid in bed mobility and/or transfers warrants the risk associated with the use of the side rail.

The resident involved had been a resident at the nursing home, but was relatively new to the room where the incident occurred.  In his prior room, the bed was equipped with a side rail.  However, in his new room, the bed in his new room did not have side rails.

On the day of this nursing home fall, he was receiving incontinence care form an aide and was positioned on his side, bracing himself with his arm against the wall.  The aide removed the brief and was placing a new brief underneath him.  As she did so, he rolled out of the bed, suffering a fractured hip which required surgical repair.

When he was in his prior room with the bed with the side rails, he would use the side rails to maintain position while receiving incontinence care.  Facility policies called for continuing all interventions which had proven successful in preventing falls.  The practice at that nursing home had been to move a resident’s bed with them when they were moved to a new room.  This was not done, and the resident was provided with a bed that had no side rails.  Had the resident been provided a bed with side rails, he would not have had to be positioned as close to the edge of the bed to reach the wall and would not have had so much weight hanging off the edge of the bed, placing him at greater risk for falling from bed.

Further, investigation showed that there were no assessments of the resident’s bed mobility or side rail assessments in the resident’s chart.  Had these been done, it is likely this resident’s care plan would have called for assistance of two staff during incontinence care or the use of side rails for assistance with bed mobility.  Either of these steps would have likely prevented this fall and injury.

There were a number of breakdowns in the care of this resident which led to the fall and broken hip.  First, there was the lack of proper assessments which led to issues relating to bed mobility not being addressed in the resident care plan.  Second, the facility policy of continuing effective fall prevention measures was not followed in that side rails were not incorporated when the resident changed rooms.  Finally, the practice of moving the bed with the resident was not followed.  Any one of these would likely have prevented the injury to this resident.

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.

Other blog posts of interest:

Westminster Village resident breaks leg in fall from toilet

Failure to activate chair alarm results in fall and brain bleed at Pleasant Meadows in Chrisman

Tuscola Health Care resident dropped from lift, breaks ankle

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Dimensions Living nursing home in Prospect Heights after a resident there was involved in two falls in four days – the first resulting in a broken jaw, the second resulting in facial fractures.

One of the basic truisms in the long-term care industry is that if a nursing home is unable to meet the care needs of a resident, the only proper course is for the nursing home to decline the admission of that resident.  In fact, federal regulations require that nursing homes have enough properly trained staff on had to meet the care needs of its residents on a 24/7 basis.

This resident was admitted to the nursing home from an assisted living facility.  The reason that the transfer was made was that the resident was having frequent falls in the assisted living facility, and one of the well-recognized truths about falls in a long-term care setting is the falls tend to beget more falls.  A history of recent falls is a factor that is accounted for in almost all fall risk assessment tools.

And this resident was in fact a fall risk – in addition to the history of falls, she also suffered from cognitive impairments with diminished safety awareness.  She also had generalized weakness and and required extensive assistance with transfers and mobility.  Her assessment concluded with a statement which stated that she required one-on-one care.

The first nursing home fall occurred approximately a month after the resident was admitted.  She was seated in a wheelchair doing an activity.  The activity aide assigned to run the activity was passing out to drinks to other residents when the resident fell forward from her wheelchair and hit the ground, suffering a fractured jaw.

The second fall occurred four days later.  The resident was again brought to the dining room for activities being conducted by an activity aide.  The resident again had another fall, this time hitting her head, resulting in significant bleeding and a lost tooth.  The resident was sent to the hospital due to complaints of pain and having a hard time breathing.  There a CT scan showed that she sustained facial fractures.

The resident’s assessment showed that she required a significant degree of supervision.  She was an obvious fall risk in light of her history of falls, cognitive impairments, poor safety awareness, and generalized weakness.  The assessment recited that she required one-on-one assistance, which is a level of care that nursing homes generally claim is impossible.  The facts here show not only did the nursing home fail to provide the care which they recognized in the assessment that she required, but they failed to provide the adequate supervision called for by federal regulations.  The activity aide was charged with not only conducting the activity, but also supervising the multiple residents who had been brought to the activity without the help of additional staff.  Inadequate supervision leads to fall, and did so here.

One of our basic 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.

Other blog posts of interest:

Grove of Skokie resident breaks leg due to violation of care plan

Grosse Pointe Manor resident falls and breaks hip after being left unattended

Resident breaks both legs in unsafe transfer at Symphony of Buffalo Grove

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and and fined Fair Oaks Rehabilitation & Health Care Center in South Beloit after a resident there fell and suffered a broken hip due to the failure of a therapist to use a gait belt while walking with the resident.

Use of a gait belt is a fundamental fall prevention strategy.  A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers.  The gait belt allows the staff member assisting the resident help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall.  Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall.  Either places both staff and resident at risk for injury.

The resident at issue was considered at risk for falls and had been assessed as not being steady during transitions and walking and required the extensive assist of one staff member with walking in the corridor.  Extensive assist has a particular technical meaning – it means that the staff member is providing some physical assistance with the weight bearing.  Doing this properly requires the use of a gait belt.

On the day of this nursing home fall, the resident was being walked back from therapy by a COTA (certified occupational therapy aide).  There was no gait belt in use.  The aide later told the state surveyor, “[The resident] should have had a gait belt on for a security belt because she was unsteady.  I should have had a gait belt on her.  I don’t know why I didn’t use one.”  As they walked down the hall, a nurse sitting at the nurse’s station observed the resident and the aide, later telling the surveyor that it looked like the aide was not paying attention.  The resident began to tire and reached back to sit in a wheelchair, but instead fell to the ground, suffering a fractured left hip which required surgical repair.

Here, there was a failure in the fundamentals which led to this fall.  And it was not for a lack of equipment – the rehab director told the state surveyor that there was a drawer full of gait belts available in the therapy department.  Simple failures lead to very preventable accidents.

It is worth noting that the primary culprit in this incident was the therapy aide.  Frequently in nursing homes, therapy services are provided by an outside contractor.  However, the therapy aide was not the sole person bearing some responsibility for this fall as the nurse saw the aide walking with the resident and failed to act to correct the dangerous situation of walking the resident with no gait belt.

One of our basic 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.

Other blog posts of interest:

Pleasant View Rehab resident fractures hip in fall

Bethany Rehab resident breaks arm in fall

Multiple falls leads to fall with broken hip at Tower Hill

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center nursing home in Chicago Heights after a resident there suffered a fractured leg after falling eight times in just over a year, with seven of the falls (including the last) being caused by her attempting to go to the bathroom unassisted.

One of the common situations where falls occur in nursing homes is when the resident attempts to go to the bathroom.  Nursing home residents are adults and when they are able to control their bowel and bladder and have sufficient cognitive wherewithal to recognize this, the desire to maintain their dignity takes over and they will attempt to make it to the bathroom unassisted, often leading to disastrous outcomes.

Before the fall at issue, this resident had 8 prior falls in just over a year’s time.  After each fall, the staff did the right thing and performed a root cause analysis in an effort to determine why the fall occurred.  When there is a root cause found, then there should be changes to the fall prevention care plan to take steps to prevent further falls.  The net result of the root cause analysis for 6 of the prior falls is that the root cause was the resident attempting to go to the bathroom unassisted.  Further to the nursing home’s credit, the care plan was upgraded five times to include getting a urinalysis, use of floor mats, a referral to physical therapy, rounding every 2 hours, and then finally rounding frequently and keeping resident in area where she could be supervised.

On the day of this nursing home fall, the resident was attempting to go to the bathroom unassisted and fell again.  This time, she suffered a fracture of the femur which resulted in her being wheelchair bound.

The nursing home did many things right in the care of this resident.  She was clearly a fall risk and was treated as such.  When she sustained falls, there was an effort made to determine the cause of those falls and to try to prevent further falls.  However, there was a common theme among almost all the falls in that she was attempting to go to the bathroom unassisted.  One means of addressing the behavior would be to put the resident on a toileting schedule.  This would involve the staff tracking the resident’s bathroom habits over  period of several days so that the patterns could be discovered, and once those are identified, the staff would be scheduled to bring the resident to the bathroom when the need was expected.  This was never tried for this resident, leading to repeat falls with changes in the care plan of dubious value.

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.

Other blog posts of interest:

Symphony at Palos Park suffers brain bleed in fall from toilet

Prairie Manor resident suffers brain bleed after being rolled out of bed

Mechanical lift accident at South Holland Manor

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Symphony of Palos Park nursing home after a resident there suffered a brain bleed as a result of a fall which occurred due to him being left unattended while seated on a toilet.

Federal regulations pertaining to nursing home falls call for residents to receive supervision and assistance as needed to prevent accidents.  Falls are a form of accident, and the regulations require nursing homes to take the required measures to prevent this kind of accidental injury.  How does the staff know what has to be done to prevent falls?  The basic answer to that is the care planning process.

During the care planning process, there is an assessment done of the risks to the health and well-being of the resident.  This results in a care plan being developed which sets forth a specific set of measure which staff members are assigned to carry out on a day-to-day, shift-to-shift basis.  The care plan must be communicated to the staff charged with carrying it out and then it must actually be implemented.  Finally, its effectiveness must be evaluated on an ongoing basis and then revised if there are changes in the resident’s needs or it proves to be ineffective in practice.

The resident at issue had a number of medical conditions which placed him at risk for falls, including a history of epilepsy, cognitive impairments, and generalized weakness.  The resident was assessed on multiple occasions using the facility’s fall risk assessment tool which scored him consistently as 18 or higher.  On the fall risk assessment tool used at this nursing home, any score 10 or higher indicated a high risk of falls and required that the resident be placed in the “red leaf” fall prevention program.  Staff were trained that residents who were in the red leaf program were not to be left unattended on toilets.

On the day of this nursing home fall, the resident was brought to the toilet by an aide.  The aide who brought the resident to the toilet then left to get a beverage for the resident, telling him to pull the call light when he was finished.  When the aide returned to the room, she found the aide on the floor.  The resident was sent to the hospital where he was diagnosed as suffering from a brain bleed.

There was clearly a break down in the care that this resident received.  He was assessed as a fall risk and the nursing home had a reasonable procedure in place to address that fall risk: that residents should not be left unattended while seated on a toilet.  One reason for this is that it actually requires a significant amount of trunk control to maintain position on the toilet.  Unfortunately, either the risk level for this resident was not communicated to the aide involved, or she was not properly trained on the red leaf fall prevention program.  In either event, this breakdown in the care led to this resident’s fall and injury.

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.

Other blog posts of interest:

Westmont Manor resident suffers brain bleed after being rolled from bed

AHVA Care of Stickney resident breaks hip in fall

Failure to supervise Westmont Manor resident leads to fall and broken hip

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Generations at Elmwood Park nursing home after a resident there suffered a broken hip in a fall.

Nursing homes are required to complete a series of documents called the Minimum Data Set (MDS).  The MDS is submitted under penalties of perjury to the federal government and is a statement as to the condition of the resident and the levels of care and assistance that the resident requires.  The reason that the MDS is submitted to the federal government under penalties of perjury is that the MDS forms part of the basis by which the nursing home is paid and this is the certification by the nursing home that a) this is the kind of care that the resident requires and b) that the nursing home is in fact requiring it.

The resident at issue was 101 years old and was wheelchair bound, but was largely independent.  However, her MDS certified that she required assistance of one staff member with getting her pants on.  This was confirmed by the nursing home’s occupational therapist who confirmed that she needed at least supervision with getting her clothes on her lower body.  However, most staff members charged with her care believed that she was independent in all aspects of daily living, including dressing herself.

On the morning of this nursing home fall, the resident was seated in her wheelchair in her room getting ready for the day.  Staff present in her room knew that she was getting dressed but no one waited to provide supervision and assistance with her getting her pants on.  She attempted to do so herself but lost her balance while standing to pull her pants up and fell.  She landed to one side and was assisted back to bed by staff.  However, the fact that a fall occurred was not communicated to the resident’s doctor so it was not until the following day that she was sent to the hospital after staff heard her telling her family about the fall and that she was having pain in the side.  There, the fractured hip was diagnosed and treated.

Nursing homes are businesses, and well-run businesses have processes that must be followed to ensure that necessary services are provided as a matter of routine.  This should include incorporating care called for in the MDS into the resident care plan, having the contents communicated to the staff charged with carrying it out, and then having that care actually delivered.  Here there were multiple breakdowns in the delivery of care.  The care called for in the MDS was no incorporated into the care plan, communicated to the staff, or actually delivered.  The assessments clearly called for supervision and assistance with putting on pants but that was not done.  As a result, this resident fell and suffered a fractured hip.

Past that, a fall is something that requires physician notification.  This was not done until the following day leaving the resident with no care of relief from pain from the fractured hip.  When asked, most nurses working in a nursing home setting will agree that subjecting a resident to unnecessary pain is a form of nursing home abuse.

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.

Other blog posts of interest:

Inverness Rehab resident suffers multiple fractures in fall

Tower Hill resident suffers fractured hip in fall

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there suffered a broken leg in a fall while getting up from the toilet.

Falls are a major source of concern in the long-term care industry.  Falls are associated with increased mortality rates, steep declines in the quality of life when there is significant injury, and increased risk of falls in the future.  For these reasons, and because of the requirements of federal regulations, fall risk is a specific area of focus in the care planning process.

When fall risk assessments are done, the nursing home will use its assessment tool to evaluate the resident’s fall risk.  Two factors that are in in all well-done fall risk assessment tools are (1) some form of gat/balance/musculoskeletal dysfunction and (2) some form of cognitive impairment such as intermittent or constant confusion, dementia, poor safety awareness or judgment, and/or impulsivity.  These combine to make the resident a fall risk because the physical issues leave the resident at risk for falls or loss of balance and the cognitive deficits increase the chances that the resident will not follow instructions, ask for assistance, or make good decisions for their own safety.

This resident had many of the factors that made her a fall risk.  Her Minimum Data Set (MDS) indicated that the resident had moderate cognitive impairments, that she required extensive assist of staff with transfers, toileting, and personal hygiene, and that she was unsteady when rising from a seated to standing position and was only able to stabilize with staff assistance.  The resident had a known history of attempting to rise from the toilet unassisted – something which could result ion a fall.

At the time of this nursing home fall, the facility had in place a policy which stated residents who are i9dentified as being at risk for falls if left unattended on the toilet should not be left unattended while on the toilet.

On the day that the fall occurred, the resident was brought to the toilet by an aide who then left the resident to go get hair rollers.  While she was doing that the resident attempted to rise from the toilet unassisted and fell.  She was brought to the hospital where a broken femur was diagnosed.

This is a resident who was at risk for just this kind of fall based on the documented findings of cognitive impairments and difficulty with standing from a seated position – all documented on her MDS,  as well her known history of attempting to get up unassisted from the toilet.  Based upon prevailing standards pf practice as well as the facility’s own policy, this resident should not have been left unattended.  The administration of the nursing home agreed with this, writing the aide up.

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.

Other blog posts of interest:

Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt

Westminster Village resident suffers multiple fractures in fall

Resident breaks hip in fall at McLean County Nursing Home

Christian Nursing Home resident suffers severe leg injury in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Park Pointe Healthcare and Rehab nursing home in Morris after a resident there suffered multiple fractures due to falling down a stairwell.

The resident involved in this fall down the stairwell had a care plan for wandering. Wandering is also known as elopement in the long-term care industry and is a serious risk of harm to the resident. Residents who wander can find themselves in situations where they are faced with hazards which due to physical or cognitive limitations, they are unable to safely face or address. This resident was also a fall risk because she was wheelchair-bound and had musculoskeletal deficits as well as significant cognitive deficits.

For residents which are at risk of harm due to wandering/elopement or falls, there are a number of steps that can be taken to mitigate that risk.  One of the principal steps is to keep the resident under close supervision.  Doing this reduces the risk from injury for both falls and wandering, and is consistent with the requirements of federal regulations.

On the day of this nursing home fall, the staff noticed that a plastic curtain, which went to an otherwise-empty COVID unit, had been disturbed. The staff checked the rooms in the COVID unit for  residents but did not find any. They returned to their own unit and discovered that the resident involved in this incident was missing.

They looked throughout the facility but were unable to locate her and returned to the COVID unit.  Upon return to the COVID unit, they re-inspected all of the rooms and were unable to find the missing resident. Coming to the end of the hallway, they noticed that the door to the stairwell was closed, but the green light for alarm was flashing. This was an indication that the alarm was not armed.

The staff opened the door and found the resident down at the bottom of the stairwell, with her wheelchair two or three steps down the stairwell. She apparently had begun to fall down the stairs. The wheelchair stopped, and she was ejected from the wheelchair. An ambulance was called. The resident was brought to the hospital where she was diagnosed as having a fracture to her clavicle, as well as broken ribs.

There were two major shortcomings in the care that this resident received. First, any resident who is at risk for falls and is also known as a wanderer and at risk for elopement should be a resident who is closely supervised. The citation issued by IDPH indicates that the staff was well aware of her history of wandering and that she wandered actively throughout the facility, often looking for her husband, who is in fact, not a resident at the facility.  Keeping her under close observation would have likely prevented this injury, especially given the amount of time that it would have taken her to travel that distance and open not only the door to the stairwell, but also the curtain to the COVID unit.

The other major shortcoming in the care that this resident received is that the stairwell was not secured with either a lock or an alarm. Stairwells pose a special risk of harm to nursing home residents.  This is partially due to the fact that many are simply not able to negotiate them safely as well as the fact that stairwells are an area where they are out of view of the staff.  Once a fall occurs in a stairwell, it is likely that the resident will endure a prolonged period of time before the fall is discovered and care for any injuries from the fall can be offered.

In this particular case, the practice at the nursing home was that the maintenance staff would check the alarms throughout the facility during weekdays, but there was no one specifically assigned to check the alarms on weekends – which is when this fall occurred. As a result, the stairwell was not secured with locks or alarm leading to the fall and injuries sustained by this resident.

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.

Other blog posts of interest:

Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell

Accolade of Pontiac resident fractures hip in fall after call light left out of reach

Resident breaks both legs in fall from bed at Grove of Fox Valley

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Piatt County Nursing Home after a resident there fractured a hip in a fall due to the failure of an aide to provide needed supervision and assistance.

Falls are a major issue in the long-term care industry due to the serious negative effects that they have on the mortality and quality of life of nursing home residents.  Therefore, fall prevention is always a specific area of focus in the care planning process.

The care planning process begins with an assessment of the resident’s fall risk.  Nursing homes use a variety of tools to assess fall risk, but one common feature in almost all tools is that (1) some form of musculoskeletal weakness, balance issue, or gait dysfunction and (2) some form of dementia, forgetfulness, intermittent or constant confusion, poor safety awareness or judgment, or some other form of cognitive impairment are major factors in weighing the resident’s fall risk.  The reason that cognitive impairment contributes to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Where cognitive impairments are a contributing factor to fall risk, close supervision is a mainstay of fall prevention – consistent with the requirements of federal regulations.

The resident at issue was properly assessed as being a fall risk.  Among the factors that made the resident a fall risk were having mobility impairments, poor balance, an unsteady gait, a history of falls, and according to the resident’s Minimum Data Set (MDS) he required extensive assist of the staff with transfers and to stabilize.  On the cognitive side, he was noted to have long and short term memory problems.  He further had a known history of attempting to self-transfer and forgetting to use the call light.  He was considered a fall risk because of his impaired gait and forgetting and/or overestimating his limits.

On the day of this nursing home fall, the resident activated the call light for assistance to use the commode.  The aide arrived to assist the resident.  He provided the resident his walker and then turned and went to close the privacy curtain for the resident.  As the aide was closing the privacy curtain, the resident attempted to stand using the walker.  As he did so, he lost his balance and fell to the floor.  The resident’s leg was rotated outward with a leg length discrepancy – obvious signs of a fractured hip.

The resident was brought to the hospital where the fractured hip was confirmed.  The resident was transferred to a larger hospital where he underwent surgery to repair the fractured hip.

The facts of this fall show how quickly small failures in the care that the resident is provided can have catastrophic consequences.  The aide responded to the call light (something that does not always happen) and attempted to provide the resident with a measure of dignity by closing the privacy curtain.  However, he did so after providing the resident with the walker.  He was not in a position to provide the resident with the needed assistance with transferring and stabilizing when he rose from the position seated at the edge of the bed.  Further, he had his back turned to a resident whose known history and behaviors spoke to a need for close supervision.  The Director of Nursing admitted as much, telling the state surveyor that simply closing the privacy curtain when he entered the area could have prevented this 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.

Other blog posts of interest:

Piatt County Nursing Home resident breaks neck in fall from power recliner

Westminster Village resident suffers multiple fractures in fall

Moweaqua Rehab resident fractures hip in fall

Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt

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