IDPH has cited and fined the Villa at South Holland nursing home after a resident sustained a fractured hip as a result of a fall.
When we review potential nursing home cases, especially those that involve the kinds of events that happen frequently in a nursing home setting such as nursing home falls, bed sores, or injuries resulting from elopement or wandering, the first parts of the chart we look at are the resident assessments and care plan. When a resident is admitted to a nursing home, the staff performs a comprehensive assessment which is intended to identify the risks to the health and well-being of the resident. Based on the results of that assessment, the care plan is developed which sets forth a series of steps that should be taken on a day-to-day, shift-to-shift basis to address the risks identified during the assessment.
There are a number of ways that we look at the assessment and care plan. First: were reasonable assessments done? If the assessments are the basis of the care plan, bad assessments yield bad care plans. Second: was the care plan adequate? We will address that in a moment, as that was an issue in this situation. Third: was the care plan actually implemented? Having a great care plan is useless if it is not being carried out, and that has been the issue in other situations, such as here, here, and here. Finally, was the care plan revised and updated in light of experience and/or changes in the resident’s condition? If the care plan proves inadequate in practice (as might be shown by the occurrence of falls or the development of new bed sores, assuming that those areas had been targeted in the care plan) or the resident has changed care needs after the care plan is developed, it needs to be changed.
Getting back to the situation at hand – this was a situation where the care plan itself was not adequate, and in many ways, this care plan was typical of many that I see. Many of the care plans I see consist of a set of check boxes which are marked. Frequently, there is not a lot of thought given to including specific steps which needs to be taken top meet the care needs of the resident – care plans are supposed to be individualized to meet the care needs of the resident. You also see things included in the care plan which are so general that it does not create any real accountability on the part of the staff to accomplish these things.
This resident was a classic high fall risk resident. She had significant musculoskeletal issues, but also had poor insight into her own condition and made poor judgments regarding her own safety. Before the fall at issue here, her fall prevention care plan included the following steps: 1) make sure that she uses appropriate footwear, 2) place call light in reach, encourage her to use it, and respond promptly, 3) follow facility fall protocol, and 4) PT to evaluate and treat as ordered or needed. After experiencing two falls before the one at issue, a bed alarm and chair alarm were added as interventions.
During the course of the survey, the staff agreed that for a resident with that kind of profile, frequent rounding or monitoring should have been a part of the care plan. The “facility fall protocol” referred to the facility’s own policies and procedures, which listed frequent rounding and monitoring as a fall prevention measure. Federal regulations relating to nursing home falls require that nursing homes provide supervision and assistive devices necessary to prevent accidents. Despite all of this, providing frequent monitoring and rounding and keeping the resident under observation was not a part of the care plan.
At the time of the accident, the resident was unattended in the dining room. The nurse was passing medications, and the assigned CNA was in another resident’s room. The resident apparently got up from her wheelchair to walk somewhere on her own and fell, as she was found just inches from her wheelchair. After she complained of leg pain, she was brought to the hospital where x-rays showed that she had a broken hip.
This was a resident who had a new for close supervision. She was properly assessed as a high fall risk, and one of the key factors for this was her own poor judgment for her own safety. When this is present, this requires close supervision by the nursing staff. However, this was not a part of her care plan, and was clearly not a part of the care that was in fact being delivered to this resident. A poor care plan led to a poor outcome – a broken hip for this resident.
This is situation where no real critical thought was given to the care plan, and as a result this nursing home was dodging bullets for weeks leading up to this fall, especially in light of the two falls that led up to this. 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 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:
Resident breaks in leg in failed mechanical lift transfer at South Holland Manor
Resident rolled from bed at South Holland Manor
No fall prevention care planning at South Suburban Rehab
Lack of footrests on wheelchair leads to broken ankle at South Holland Manor
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