IDPH has cited and fined Regency Care of Sterling nursing home after a resident there fell from bed and suffered a brain bleed which resulted in his death.
The resident at issue was considered a fall risk and had an extensive fall prevention care plan. This included the use of a bed alarm and half side rails on both sides. A bed alarm is a pressure-sensitive strip which is placed under the resident’s sheets. When the pressure from the resident’s body weight is reduced, the alarm is supposed to sound. This should bring an immediate staff response while at the same time serving as a reminder to the resident that he should not be up unattended. The side rails are not directly intended to keep a resident from getting out of bed (as that would serve as a restraint), but do help the resident move safely in bed and get in position to transfer out of bed safely.
This nursing home fall was discovered by an aide who found the resident on the floor next to his bed. One side rail to his bed was up and the alarm was not sounding. It was not clear who disarmed the alarm or lifted up the side rail, but the resident was unable to move the side rails independently. Exactly how the alarm was disarmed and the bed rail lifted was not clear from the citation, but given his physical limitations, it was likely a staff member who did this.
When the aide discovered the resident on the floor, it was apparent to her that the resident likely struck his head on the floor even though there was no obvious injury. She notified the nurse who helped get the resident off the floor and did an assessment of the resident. The occurrence of a fall is an event that requires physician notification. This was especially true in this situation as the resident was on Plavix, a medication which inhibits the body’s ability to form blood clots and stop bleeding. This resident also had a history of brain bleeds, which meant that he was susceptible to experiencing an uncontrolled brain bleed after a fall. Notifying the doctor would have allowed the doctor to decide whether or not the resident should have been sent to the hospital.
Normally, when a resident experiences a fall, they are put on a 72-hour fall watch to see if they show signs of injury which are not immediately apparent from the fall. This process usually starts with checks being made at fifteen minute intervals at first and then having larger intervals over the period of the watch. This resident’s fall was discovered at approximately 7:00 a.m., but the doctor was not notified of the fall until after 11:00 a.m. when the resident’s wife brought a change in the resident’s condition in the form of seizure-like activity to the attention of the staff. After attempting to reach the doctor, the nurse on duty called 911 and the resident was sent to the hospital.
On arrival, a CT scan of the brain was performed which showed an acute subdural hematoma. The resident did not survive this brain bleed, resulting in the wrongful death of the resident five days later.
There are a couple of separate issues with the care that this resident received. The first relates to the occurrence of the fall itself. The bed alarm which was supposed to serve as a warning to the staff that the resident was getting out of bed had been disarmed. Including a bed alarm in the care plan is only an effective intervention where the alarm sounds when the resident starts to get out of bed. Disarming defeats the entire intervention. Further, even though the side rails are not intended to serve directly as a means to keep residents in bed, they do have that effect, and since the resident was unable to move the side rails himself, that points at a staff member as being the likely person who moved them, especially given the time of day that the fall occurred. Second, his post-fall care was deficient in that the doctor was not notified of the fall. After a fall occurs, the resident’s doctor must be notified. When interviewed by the state surveyor, the nurse practitioner who was on call that morning for the resident’s doctor indicated that she would have ordered him sent to the hospital – a prudent measure in light of the medications he was taking. Further, it is not clear that the checks which are a standard part of the 72-hour fall watch were either done or done properly, as the onset of seizure activity is something that would be associated with significant pressure from the brain bleed. There would have likely been indications of neurologic impairment before that which were not detected if the checks that are part of the 72-hour fall watch were done properly.
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: