IDPH has cited and fined Heritage Health nursing home in Mt. Zion after a resident there suffered a fractured hip in a fall.
The care planning process is a staple of nursing home care, and even though this is something that needs to be done for every resident, the actual care plan is supposed to be individualized to the risks and needs of the particular resident. The federal regulations in fact refer to this as “comprehensive, person-centered care plans.” This means that while there are a range of standardized assessments that are used in the care planning process, the care plan should reflect the needs of THAT particular resident and provide the safety and well-being of THAT particular resident in a way that is appropriate.
The resident at issue here suffered from advanced dementia and was recognized as a fall risk. There was a fall prevention care plan which included many of the usual fall prevention steps. However, the staff recognized from experience that she would become very agitated when her husband would leave the nursing home after visiting her and would get up from her wheelchair to leave, saying that she needed to go home and be with her family. When her husband would leave, the staff would place her in her wheelchair in the hallway so that she could be supervised by staff. In the past, they would also give her a word search puzzle to do, but had found lately that this did not work as well because her advancing dementia made finding the words more difficult. While these are reasonable steps to take, they were not incorporated into her care plan nor were their diminishing effectiveness taken into account.
On the day of this nursing home fall, the resident’s husband had come to visit. After he left, the resident was brought out into the hallway by her room in her wheelchair so she could be supervised by staff. At some point, the resident got up from her wheelchair, saying that she needed to go with her family, setting of her chair alarm. At that moment, all of the aides were in resident rooms attending to the needs of other residents. One of the two nurses on the hall was on the phone. The other nurse raced to get to the resident, but was not able to get there in time, and the resident fell backwards.
She suffered a broken hip in the fall which required surgery. Hip fractures are significant injuries for anyone, but especially so for senior citizens. For people in this age group, hip fractures often lead to a significant deterioration in the quality of life and frequently lead to the death within a peiod of months following the fracture.
So – what did the nursing home do wrong here? There are are really two major issues.
First, there were shortcomings in the fall prevention care planning in a couple of respects. The resident was properly assessed as a fall risk and reasonable steps were put into place to address her fall risk generally. However, the particular, individualized risk of falls associated with her agitation when her husband left were not addressed at all. The staff knew that steps had to be taken to address that, but without incorporating those steps into the care plan, these steps amounted to random acts of care which did not address the specific, predictable risks of falling for this particular resident.
The other way in which the care planning process fell short is that nothing addressed the diminishing effectiveness of the steps that were being taken to address the fact that it was getting harder to manage the resident’s agitation after her husband left. The staff had managed her agitation by giving her word search puzzles to do but that wasn’t working as well because her advancing dementia left her unable to do the puzzles. Since that tool wasn’t working, as a “care plan” these steps needed to be changed.
Second, the resident wasn’t placed in an area where she could be effectively monitored and assisted by the nurses on duty. Residents in need of close monitoring are customarily placed by the nurse’s station not down the hallway. It is entirely predictable that aides might all be off the hall attending to residents in their rooms, and leaving residents far from the nurse’s station means that the nurses may not be able to reach a resident in time, as happened here.
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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