IDPH has cited and fined Elmwood Nursing & Rehabilitation Center nursing home in Maryville after a resident fractured his left hip in a fall, underwent surgery to repair that fracture, and then dislocated that same hip in a fall occurring five days after his return to the nursing home.
The initial nursing home fall occurred for a simple reason: the resident was wearing two different shoes which were of different heights leading to a loss of balance and the fall which resulted in the hip fracture.
The citation issued by IDPH does not mention whether this resident was considered a fall risk prior to the fall where the hip was initially fractured. It appears that he was walking independently when the fall occurred, but the citation also references a statement from a nurse who described the resident as being some degree of confusion before the fall occurred. Regardless of whether the resident was considered a fall risk, having residents in proper footwear is considered a basic fall prevention measure that should be employed for all residents. Having shoes of different height contributing to loss of balance falls short of that standard, and if the resident was demonstrating confusion even before the initial fall, simple checks on the resident were likely in order.
After the initial fall occurred, the resident was brought to the hospital where he underwent surgical repair of the fracture. Three days after the fall occurred, he was returned to the nursing home for further care and rehabilitation.
Upon his return to the nursing home, he would definitely be considered a fall risk based upon his history of a recent fall, together with the weakness and general musculoskeletal dysfunction from the original injury. The fall prevention care plan included monitoring per facility protocol and reminding the resident to use a call light. The nurse referenced earlier also advised the state surveyor that after returning from the hospital following the hip fracture, the resident demonstrated increased confusion. Constant or intermittent confusion, dementia, poor safety awareness, or other cognitive impairments can be a major fall risk factor because the resident can no longer be counted on to follow instructions or make good decisions for their own safety.
The second fall occurred when the resident was found on the floor of his room five days after returning from the hospital. He could not be supervised at the nurse’s station because he was required to be quarantined due to COVID restrictions. The inability to supervise the resident along with the increased confusion that followed his readmission to the facility rendered the care plan ineffective because the regular pattern of supervision was not practicable and the resident could not be relied upon to use the call light. Poor care plans here led to poor results, and that is what happened here.
The resident was brought to the hospital where it was discovered that the recently repaired hip had been dislocated. Care for this injury will complicate the recovery from the initial injury and diminish the chances that the resident will ever be able to walk again. Immobility increases the risk of further complications such as the onset of pneumonia, the development of blood clots, and/or the development of bed sores.
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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