IDPH has cited and fined Westmont Manor & Rehabilitation nursing home after a resident who was a known fall risk there was left unsupervised at the nurse’s station, and a result fell and suffered a fractured hip which required surgery.
When a resident is considered a fall risk, developing and implementing a fall prevention care plan is required. One of the mainstays of a good fall prevention care plan is keeping residents who are at risk for falls in an area where they can be easily supervised by staff. In fact federal regulations require that residents receive supervision and assistance necessary to prevent accidents, and falls are definitely accidents. In practice, this means that residents who are at risk for falls are placed in areas like the dining room, the activities area, or by the nurse’s station so that staff can keep them under direct observation. This of course requires staff to actually be present in those areas.
The resident at issue was a known fall risk, and in fact before the fall at issue, had three prior falls. One of the truisms about nursing home falls is that the occurrence of a fall is a predictor for additional falls and is a factor considered in almost all high-quality fall risk assessment tools. Other crucial factors include some type of musculoskeletal or gait dysfunction and some form of cognitive impairment such as confusion, dementia, or poor safety awareness of judgment. The reason that cognitive impairments feed into fall risk is that the residents cannot be counted on to make good judgments for their own safety or follow instructions from the staff intended to minimize fall risk.
This resident was wheelchair bound and required the extensive assistance of two staff with transfers and suffered from dementia. She also had poor trunk control and had a history of stroke. With the history of multiple falls and her physical and cognitive impairments, she was properly assessed as being a fall risk, and a fall prevention care plan was put into place. One of the steps in that fall prevention care plan was to keep her in an area where she could be supervised while up.
On the day of this nursing home fall, the resident was brought to the nurse’s station in her wheelchair. The nurse was due for his break, so he went into the dining room – just a short distance from the nurse’s station. While he was on break, an aide was assigned to monitor the residents at the nurse’s station. However it was also the time for shift change for the CNA’s, so the aide was down at the other end of the hallway getting ready to end her shift. As a result no one was monitoring the residents at the nurse’s station.
While he was sitting in the dining room on break, the nurse heard a thud. He went to the nurse’s station and found the resident on the floor. He went and got the aide who was getting ready to leave and returned to the resident. He assessed the resident and then got her off the floor. The resident had a bump on the forehead and was complaining of pain in the left hip, so the resident was sent out to the hospital.
At the hospital, scans showed that the resident had a femoral fracture extending into the intertrochanteric space – in lay terms, a fractured hip. She underwent surgery with the placement of nails to repair the fracture.
This fall was the direct result of a violation of the resident care plan. The whole point of having the resident in a location where she could be monitored is so that someone would be watching and in a position to intervene if she attempted to get up unassisted – a known behavior for this resident. However, when the nurse assigned took his break and the aide left the nurse’s station to get ready to go home, the resident was left unsupervised. Care plans need to be implemented on a 24/7 basis – and this is the result when they are not.
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: