IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there suffered a serious injury to her leg after a fall after experiencing two falls during the first three days she was in the nursing home.
The resident at issue was admitted to the nursing home for rehabilitation after having a stroke which left her with some left-sided residual weakness. Before that, she was living in the community and had 24-hour care because she had some issues with dementia.
When a resident is admitted to a nursing home, a care plan must be developed. There are six basic steps to the care planning process. First there is an assessment of the risks to the health and well-being of the resident. Second, a care plan outlining the various steps, or interventions, which must be taken by the staff on a day-to-day, shift-to-shift basis to address the risks identified during the assessment. These must be tailored to the specific needs of the resident. Third, the care plan must be communicated to the staff. Fourth, the care plan must in fact be implemented on a day-to-day, shift-to-shift basis. Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis. Sixth, it must be revised when it proves to be inadequate in practice of due to changes in the condition of the resident.
One area that is always assessed in the care planning process is the resident’s fall risk. This is because falls are a well-recognized threat the life and well-being of nursing home residents and because there are federal regulations on falls. There are no gold standard tools for assessing fall risk in nursing homes like how the Braden scale is used for the risk of developing bed sores, but almost all of the assessment tools have some features in common.
Two of the commonly recognized risk factors includes (1) some degree of musculoskeletal, gait, or balance dysfunction and (2) dementia, intermittent of constant confusion, and/or poor safety awareness or judgment. The physical aspect relates to the resident’s ability to safely walk, stand, transfer, or even maintain a seated position. The cognitive aspects come into play because where a resident has cognitive deficits or poor safety awareness or judgment, they cannot be counted upon to make good decisions for their own safety or follow safety instructions. These are factors which must be taken into account in developing the resident’s care plan.
On admission, the resident was assessed as being at high risk for falls. Findings in the assessment included: unsteadiness while walking, use of a wheelchair, rushing to use the bathroom due to incontinence of bladder, significant cognitive impairments, and impaired functional problem solving and safety awareness. The care plan included frequent checks and assistance with transfers.
The first nursing home fall occurred during the evening of the second day of her admission. The resident had been changed into clothes for bed, but within an hour was found on the floor dressed in her normal clothes. She told the staff that she wanted to get changed before her husband came home, obviously showing a significant degree of disorientation and cognitive impairment.
The occurrence of this fall was a significant event. First, it showed that the resident had more significant cognitive impairments than was perhaps initially recognized. Second, it is well-recognized in the long-term care industry that falls tend to beget more falls. For this reason, revision of the care plan was required. And it was – to add in a sign to remind the resident to call, not fall.
The second fall occurred the following day. An aide was going down the hall, shutting off lights at bed time and checking on residents. When she got to this resident’s room, she saw that the resident was not in bed. She went into the bathroom and found the resident on the floor, not wearing shoes, just socks. There were obvious signs of injury to her left leg, so she was sent immediately to the hospital. There she was diagnosed with dislocation of the hip and a fractured femur. She was then transferred to another hospital for surgery.
The investigation into this revealed a number of shortcomings in the care that this resident received. As a starting point, they failed to take into consideration the fact that the resident had 24-hour care at home and had significant cognitive deficits even though those items of information were a part of the information that the nursing home received from the hospital at the time of transfer. Had they been taken into account, the Director of Nursing admitted to the state surveyor that the resident would have been admitted to the dementia unit where the staffing patterns would have allowed for increased supervision which may have prevented the fall.
Past that there were a number of shortcomings in the care that this resident received. First there was no effort at implementing a toileting schedule for an incontinent resident who suffered from significant dementia and was a high fall risk. Second, the care plan did not include use of proper footwear – a key point since the resident was found on the floor at the time of her second fall wearing only socks. Finally, the revision to the care plan after the first fall was wholly inadequate. That first fall was her dementia and poor safety awareness/judgment in action and relying on her to read and heed a sign was foolish.
The net effect of all these is that this resident suffered a serious and unnecessary 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.
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