IDPH has cited and fined Piatt County Nursing Home after a resident there fell and suffered a fractured hip due to the failure of the staff to comply with the resident care plan which called for the use of a bed alarm and a chair alarm.
The care planning process is how much of the basic care is provided to nursing home residents on a day-to-day basis. There are six steps in the care planning process: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.
The resident involved was properly assessed as being at risk for falls. She had a number of fall risk factors. One of these was a history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls. Another risk factor was an impaired gait. Finally, the resident suffered from cognitive impairments which caused her to overestimate or forget limits. This means that she could not be counted on to follow instructions or make good decisions for her own safety.
A fall prevention care plan was put into place to address the resident’s risk of injury due to falls. Among the steps that were put into place was the use of a bed alarm and a chair alarm. These are devices which are designed to sound an alarm when the resident attempts to get out of bed or their chair or wheelchair. The sounding of the alarm serves two purposes: it alerts the staff that the resident is getting up and it reminds the resident that they should be waiting for help. The requirement for use a bed alarm or chair alarm was backed by a physician order for the staff to check that the alarm was in place and functioning.
On the day of this nursing home fall, the resident involved was suffering from a urinary tract infection. For senior citizens, urinary tract infections are well-known to cause increased confusion, and indeed earlier on the day of the fall, the resident had been noted to have increased episodes of confusion. To address the resident’s increased confusion, the resident was placed in her wheelchair and brought out into the hallway where she could more easily be monitored by staff. However, when she was moved to the hallway, the chair alarm was not taken from her room chair and placed on her wheelchair, so there was no alarm in place.
The aide who discovered the fall exited another resident’s room and saw the resident standing in front of her wheelchair. She was unsteady and fell to the floor. She was diagnosed with a fractured hip.
During interviews with the staff by the state surveyor, the aide acknowledged that the chair alarm should have been placed on the wheelchair when the resident was moved to the hallway, but that she did not know this was supposed to be done. This is a breakdown in the communications portion of the care planning process – there was a reasonable care plan in place (backed by a physician order to boot), but the staff charged with carrying it out did not know what was supposed to be done. All staff acknowledged that the use of the alarm would have alerted them that the resident was getting up and would have given them an opportunity to try to prevent the fall.
Beyond that, the whole purpose of bringing the resident out in the hallway was to keep her under direct observation. This was a reasonable thing to do given that increased confusion should have been anticipated and was in fact observed due to the urinary tract infection. The problem with this is that this was not assigned to anyone in particular, and she was left unattended in the hallway. This gives proof to the adage in business, “When it’s everyone’s job, it’s no one’s job.” Since it was no one’s job, the plan to keep her under direct observation (a good plan) was not executed, with the fall and broken hip a result.
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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