IDPH has cited and fined Pleasant Meadows Senior Living nursing home in Chrisman after a resident there suffered a fatal brain bleed as a result of a fall.
Many nursing home residents are on anti-coagulant, or blood thinner, medications such as Plavix, Xarelto, or coumadin. Blood thinner medications alter the body’s normal clotting mechanisms so that fewer blood clots or embolisms are formed. This is often essential for treating important cardiac or circulatory conditions which can cause strokes or heart attacks. However, when residents who are on anticoagulants fall, they are at risk for serious injuries such as brain bleeds or internal bleeding because blood thinners also have the effect of interfering with the body’s normal mechanism for stopping bleeding. Because of the risks associated with uncontrolled bleeding due to falls, a proper fall prevention care plan is absolutely mandatory.
The resident at issue was admitted to the nursing home from the hospital after her family brought her to the emergency room due to concerns about advancing cognitive declines and her inability to care for herself at home. At the hospital, she was considered a fall risk to the point that she had a bedside sitter. Her doctor also placed her on Plavix, an anticogulant medication.
When a resident is admitted to a nursing home, federal regulations require that a baseline care plan be put into place within 48 hours of admission with a comprehensive care plan to developed within seven days of the completion of the comprehensive assessment. However, any care plan, whether baseline or comprehensive, must be revised if it proves to be inadequate to meet the care needs of the resident or if there is a change in the resident’s condition.
When this resident was admitted to the nursing home, she was properly recognized as being a fall risk and a baseline fall prevention care plan was put into place. This included a number of standard steps or interventions, including: keeping the call light in use and encouraging its use; making sure that proper footwear is used; keeping needed items in reach; keeping pathways clear of hazards; and following facility fall protocol. The care plan further documented that the resident had poor standing balance and was unsafe with independent transfers. The care plan called for the assist of one staff member with a gait belt for transfers.
The overall picture is one of a resident who clearly a fall risk. Regardless of the specific tool this facility used to determine fall risk, a resident with balance deficits and cognitive impairments is going to be a fall risk because their musculoskeletal deficits leave them at risk for falls and their cognitive impairments mean that they cannot be relied upon to make good judgments for their own safety or to follow instructions which given to try to minimize falls. These risks are compounded with residents who suffer from incontinence because there is an increased risk that they will not wait for help while attempting to get to the bathroom before soiling themselves.
When a care plan is put into place, it must be tailored to the specific risks that the resident faces. It is not enough that all of the standard measures are taken. The ones that the resident actually requires must be taken for a care plan to be adequate. And where the resident demonstrates behaviors that increase the fall risk, the care plan must be adjusted. Here, there were a number of incidents prior to the final fall where the resident clearly got up unattended, but there were no adjustments made to the resident care plan. Staff interviews with the IDPH surveyor revealed:
- Multiple aides reported that the resident was frequently up and down on her own;
- One aide reported that she found the bedside urinal filled, indicating that the resident had gotten out of bed on her own, urinated, and returned to bed on her own;
- The resident was assisted to her chair by an aide who left her in the chair with the call light, only to return to find that the resident had gotten out of the chair and into bed without using the call light;
- One aide discovered the resident standing in her room unassisted on her way to the bathroom.
The staff also came to learn that the resident suffered from periodic incontinence, but there was no record of the staff of the staff bring the resident to the bathroom during the hours leading up to the fall.
This nursing home fall occurred on the second day after the resident was admitted to the facility. The nurse practitioner came to her her room to do her admitting physical of the resident. She found the resident in the bathroom lying on the floor with bleeding coming from the back of her head. There was feces smeared on the wall near the toilet paper dispenser and the resident’s incontinence brief was filled with feces and urine.
Responding emergency personnel arranged for the resident to be taken to the hospital by helicopter. There a CT scan confirmed that the resident suffered a subdural hematoma, a form of brain bleed. She was intubated but her condition continued to decline and she died two days later.
This is a case where the care plan was proving to inadequate in practice but the care plan was never revised. Indeed, many of the staff caring for the resident were unaware of the resident’s behaviors that placed her at risk of falling because they were not documented in the resident chart. Some of the additional measures which could and should have been included in the care plan included: frequent rounding or leaving the resident in a common area (if that was feasible); use of a bed/chair alarm which would have sounded when the resident got up unattended; and developing a toileting schedule to assure that the resident did not try to toilet herself without assistance. None of these steps were taken even thought the staff was well aware that the resident’s behaviors were placing her at serious risk of falling and suffering a significant injury due to her use of blood thinner medications. An inadequate care plan led to a preventable catastrophic injury.
The failure to document the things actually occurring with the resident and to give critical thought to the care needs of the resident is a hallmark of an understaffed nursing home. Unfortunately, understaffing is a core feature of the nursing home business model. One of our basic 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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