IDPH has cited and fined Barry Community Care Center nursing home after a resident who was a known fall risk was left unattended at the nurse’s station and fell, refracturing a recently broken hip.
Falls are a major issue in the long-term care industry because they have such significant implications for the well-being of residents. Fall risk is one of the areas which is specifically assessed during resident assessments during the care planning process. There are a number of tools that are used at different facilities, but the two common threads to assessing a resident’s fall risk are (1) some type of gait, neurologic, or musculoskeletal dysfunction which makes it difficult for a resident to walk, stand, or transfer safely, and (2) some type of cognitive deficit such as dementia, intermittent or constant confusion, or simple poor safety awareness or judgment.
The reason that cognitive deficits contribute to a resident’s fall risk is that the resident cannot be counted on to follow instructions or take basic precautions for their own safety. Because of this, keeping the resident under close observation is a mainstay of fall prevention. In fact, federal regulations pertaining to nursing home falls require nursing homes to provide supervision and assistance necessary to prevent accidents. Usually, this takes the form of keeping residents who are at risk for falls near the nurse’s station, the dining room, the activity area or some other common area where the staff can keep an eye on what the residents are doing.
The resident at issue here was admitted to the nursing home after suffering a fractured hip which was surgically repaired. The resident was assessed as being at risk for falls. The assessment included findings that the resident was oriented to person only – indicating significant cognitive deficits. Before the fall at issue, the resident had two prior falls, and the occurrence of a fall is a predictor of additional falls in the future.
On the day of this nursing home fall, the resident was brought to the nurse’s station so that the staff could keep her under direct observation. However, she apparently decided to stand on her own and fell, pulling the wheelchair down on top of her. It was recorded as being an unwitnessed fall, indicating that even though the resident was brought to the nurse’s station to be kept under observation, she was left unattended and the fall resulted.
The resident was brought to the hospital where scans showed a fracture around the prosthesis from the original hip fracture. The citation did not recite what was done to repair the fracture, but any surgical repair would necessarily be a difficult and complex operation and would result in loss of whatever recovery had been made from the original fracture. Without surgery, the chances of the resident being able to regain any significant measure of ability to bear weight would be minimal which in turn has serious negative long-term consequences for the overall health and well-being of the resident.
Whenever there is a report that staff which were required were not present, this raises a question of whether the nursing home is understaffed. Sadly, understaffing of nursing homes is a feature, not a bug of the nursing home business model. 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.
Other blog posts of interest: