IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident who was a known fall risk suffered a brain bleed due to a fall caused by the failure of the staff to activate his chair alarm.
Chair alarms and bed alarms are useful tools in preventing falls. These alarms come in two basic forms – one is a pressure sensitive strip which is placed in the chair or bed. When the pressure on the strip is lifted, this causes an alarm to sound. The other kind of alarm is referred to as a mobility alarm. It has a length of cord that is affixed to the resident’s clothing (usually between the should blades to make it difficult to remove) at one end. On the other end of the cord is a alarm box. When the cord is pulled away from the alarm box, the alarm sounds. The sounding of the alarm serves two functions: (1) it alerts the staff that the resident is up unattended – and they should respond immediately and (2) reminds the resident that they should not be up on their own.
Of course for the alarm to have an use as a fall prevention tool, the alarm has to be activated. This citation tells the story of what happens when the alarm is not activated.
The resident at issue was a recognized fall risk. His Minimum Data Set (MDS) recorded that she suffered from severe cognitive impairments, required the assistance of two staff with transfers, was not steady and was only able to stabilize with the assistance of staff, and had a history of falls with injury. His care plan called for the use of bed and chair alarms. The staff reported to the state surveyor after the fall at issue that the alarms were an effective fall prevention tool for this resident and that they were frequently going off.
On the day of this nursing home fall, the resident was brought to physical therapy. When the resident was taken from the room to go to physical therapy, the resident was in his recliner, but when he was assisted from the chair, the alarm did not go off. Upon his return to the room from physical therapy, the alarm was not activated.
Shortly after this, the resident got up from his chair and began to make his way to the hallway. As he reached his door he lost his balance, striking his head on the door frame on the way down. 911 was called and the paramedics reported in their notes that the staff reported physical therapy had not turned on the alarm. The resident was brought to the hospital where he was diagnosed as suffering a brain bleed and a fractured hand.
Here there was a clear violation of the resident fall prevention care plan. The care plan called for the use of a chair alarm. This sort of fall prevention measure is only effective if it is carried out on a day-to-day, shift-to-shift basis. The failure of the physical therapist to ensure that it was on was a violation of the care plan, likely sparked in part by the fact that it was apparently not on when the resident was taken from his room to therapy.
There were also shortcomings in the actual care planning itself. The staff told the state surveyor that the alarm was going off “all the time,” indicating that the resident was frequently up. While catastrophic falls had apparently been avoided, that was a matter of luck, not good care. Additional interventions such as keeping the resident in common areas, frequent rounding, and having a room near the nurse’s station were additional steps which could and should have been taken.
From a legal perspective, the involvement of physical therapy is an important issue because physical therapists are often not direct employees of the nursing home but are employees of an outside company which bears responsibility for the poor care of its employees. This adds an extra layer of complexity to any nursing home abuse and neglect case.
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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