IDPH has cited and fined Grosse Point Manor nursing home in Niles after a resident there fell and suffered a fractured hip after being left unattended in the dining room.
Falls are a major focus in the long-term care industry because as a whole nursing home residents are more susceptible to suffering serious injuries in falls which can easily prove fatal or have serious adverse effects on the resident’s quality of life.
Because falls are a focus, they are specifically addressed in the care planning process. There is no commonly adapted tool for measuring fall risk the same way the Braden Scale is used to measure risk of developing bed sores. However, there are two major factors that are used in just about every fall risk assessment tool I have seen. The first of these is some form of musculoskeletal, gait, or balance dysfunction or deficit. This contributes to fall risk for obvious reasons. The other is some degree of dementia, impaired judgment, or intermittent or constant confusion. This is because the resident then cannot be counted on to follow instructions, heed safety precautions, or make good decisions about their own safety.
When a resident is considered a fall risk, there are a couple of mainstay interventions or steps that can be taken to address fall risk. The first of these is to keep the resident under observation in the common areas or by the nurse’s station during hours when the resident is awake. The other is a use of a bed alarm or a chair alarm which sounds when a resident gets up out of bed or out of his/her chair. It serves two purposes: one to alert the staff that the resident is up and moving; the other to remind the resident that they should not be up unattended.
The resident at issue was 91 years of age and suffered from confusion and musculoskeletal weakness. She used a walker with the assistance of one staff member. Before the fall that led to this citation, she experienced 7 falls in a year and a half. Her care plan called for the use of a bed alarm (but no chair alarm) and for her to be closely monitored in the dining room.
On the day of this nursing home fall, the resident was in the dining room and an aide was assigned to monitor the residents in the dining room. However, the aide assigned to the dining room left to care for the other residents she was assigned to care for. While she did that, the resident got up to leave. As she walked away from the dining room unattended, her legs gave out from under her and she fell, suffering a fractured hip which required surgery.
There are a few levels of failures in the care that this resident received. First, the aide violated the care plan by leaving the resident unattended and unsupervised in the dining room. That supervision was absolutely necessary in light of the resident’s known behavior and history of prior falls. Second, this is a facility which used alarms, and chose to use a bed alarm but not a chair alarm. If the use of a bed alarm was appropriate for this resident, the use a chair alarm likely was also, especially with the number of prior falls this resident had experienced. Finally, the aide reported to the state surveyor that the nursing home was short staffed and that was why she left the residents in the dining room unattended while she went to care for others.
Federal regulations require nursing homes to have enough staff on hand to meet the care needs of the residents on a 24/7 basis. Clearly that was not the case here. Sadly, understaffing is a common feature of the nursing home business model. 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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