IDPH has cited and fined Cumberland Rehab in Greenup after a resident fell from the toilet suffering a brain bleed as a result.
The resident at issue was assessed as having moderate cognitive impairments, and needed extensive assistance with transfers and toileting. The resident was assessed as being at high risk for falls and was on the anticoagulant (blood thinner) Xarelto. The resident’s fall prevention care plan called for supervision and monitoring in providing care.
On the day of the fall, the resident was on the toilet being attended to by an aide. The aide realized that he gloves were soiled so she left the resident unattended on the toilet to get new gloves. A call light was available to her to have a co-worker give her assistance, but she chose not to use it. While she left the resident unattended, the resident fell from the toilet and suffered a lcaeration to the head and skin tears to the elbow. The resident was sent to the emergency room where a CT scan showed that were multiple brain bleeds. The laceration to the head was closed, and the resident was transferred to a trauma center for treatment of the brain bleeds.
Xarelto is a powerful anticoagulant, or blood thinner. It is usually prescribed to prevent the development of blood clots. It is often prescribed to nursing home residents who suffer from atrial firbrillation (irregular heartbeat) or who have had a history of suffering embolisms. It is a very effective drug for preventing complications relating to blood clots. However, the risk associated with its use is that when nursing home residents suffer falls, there is an increased risk of major injuries such as brain bleeds, uncontrolled internal bleeding, and severe bleeds asscoauted with fractures. This is why special vigilance needs to be exercised to prevent falls in residents who are on blood thinners such as Xarelto or Coumadin.
We often look at a resident’s care plan as a starting point of determining whether the nursing home bears any responsibility when a resident suffers injury from a nursing home fall. Here, there was a reasonable assessment done (resident was a high fall risk) and a reasonable care plan put into place (provide supervision with care). Once a care plan is developed, it needs to be carried out day-to-day, shift-to-shift. Any time the care needed is not being provided, there is a risk that the bad outcome (in this case, a fall) will occur.
Sadly, that is just what happened here. The resident who needed supervision on the toilet was left unattended and as a result, had a fall with a serious injury. This is a pretty predictable outcome, as this happens often (see here, here, and here).
One issue that we would carefully examine is why the aide left the resident unattended on the toilet. One likely reason is that she knew that it woiuld place a huge imposition on other staff members who were stretched as thin as can be because the nursing home was understaffed. 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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