IDPH has cited and fined Champaign-Urbana Nursing & Rehabilitation nursing home in Savoy after a resident there suffered a fractured hip after being left unattended in the courtyard.
Assessing fall risk is one of the standard assessments which is completed as part of the care planning process. For assessing fall risk, there are few standardized scales similar to the Braden scale (which is used to assess risk of developing bed sores), so nursing home use a variety of standardized tools. However, virtually all of them give major weight to two factors: (1) musculoskeletal weakness of dysfunction and (2) cognitive impairment which renders the resident unable to comply with safety instructions or make good decisions for their own safety.
While musculoskeletal dyfunction is obviously an important factor in determining fall risk, cognitive impairment is at least as significant, if not more. A resident with really significant musculoskeletal issues is not terribly likely to suffer injury in a fall, if they can understand and follow instructions that must be followed to keep themselves safe. On the other hand, a resident with relatively minor musculoskeletal issues but with real issues with intermittent or constant confusion which renders them unable to follow instructions or make good decisions regarding their own safety may have really significant risks of sustaining a catastrophic fall.
The resident at issue here has well-recognized cognitive impairments. She had in fact been assessed by the speech therapist (in addition to doing swallow assessments which play such an important role in keeping residents safe from choking accidents, they also do assessments and treatment of residents suffering from cognitive issues) shortly before this injury and found to have deficits in reasoning and judgment with impulsive, unsafe confused behaviors. She also had a history of falls – another key factor for determining whether a resident was a fall risk.
On the day of this nursing home fall, the resident walked out to the courtyard unassisted and began to pick dead flowers out of a flower pot. Staff saw her out in the courtyard, and brought her wheelchair to her, locked the wheelchair in place, and placed it next to a bench where they placed the flower pot. Staff then left the resident unattended in the courtyard. About ten minutes later a family member of another resident came in and reported that the resident at issue was on the ground.
She was brought to the hospital where x-rays showed that she had sustained a broken hip in the fall. She underwent surgical repair of the fracture.
So what did the nursing home do wrong? The basic answer is that this resident was left unattended. She was very clearly a fall risk with a history of falls, musculoskeletal issues, and documented cognitive impairments. If there was no fall prevention care plan in place, that would be a serious shortcoming in the care that this resident received. If the care plan did not call for keeping the resident under close observation, that is equally problematic. If the care plan called for that and the resident was left alone in the courtyard, that would be a violation of the care plan. The bottom line with residents who have cognitive impairments which leave them unable to be counted on to make good decisions for their own safety is that they must be kept under observation. That was not done here, with catastrophic results.
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: