IDPH has has cited and fined Heritage Health – Pana nursing home after a resident there was left unattended in her wheelchair in violation of her care plan. The resident tried to get up from her wheelchair on her own and fell, breaking her hip.
The care planning process is the foundation for much of the routine care that gets delivered in a nursing home setting. Fall prevention is a special area of emphasis in the nursing home setting because falls tend to beget additional falls and any fall tends to have serious long-term consequences for nursing home residents.
The care planning process starts with an assessment of the resident’s fall risk. The tools that nursing homes use to measure fall risk vary widely, but there are a number of factors that tend to be given weight: balance, gait, or musculoskeletal dysfunction; dementia or intermittent or constant confusion; incontinence; and a history of prior falls. If the resident is assessed as being a fall risk, then a fall prevention care plan must be developed which includes a series of steps or interventions that should be performed . That care plan must be communicated to the staff charged with carrying it out, and then it must in fact be implemented on a day-to-day, shift-to-shift basis. The care plan must be evaluated for effectiveness on an ongoing basis and then revised if it is either ineffective or there are changes in the resident’s condition.
Of course, it all comes down to the care plan being carried out on a day-to-day, shift-to-shift basis. The best assessments and the best care plans have no value if they are not actually implemented, and that was the source of this nursing home fall.
This resident had a history of a prior fall with a broken left hip. The Minimum Data Set (MDS) showed that the resident required extensive assistance from two staff members for transfers and had severe cognitive impairments. The assessment also noted a behavior of getting up unassisted. In short, she was a clear fall risk and was assessed as such. Part of her care plan was that when the resident was up in her wheelchair, she should be placed in a high traffic/highly visible area (in the common room or by the nurses’ station would be examples). This is a very common intervention to address this form of fall risk. The care plan was recorded on the kardex which was stored on the back of the door to the resident’s room.
On the day of this nursing home fall, the staff reported finding the resident trying to crawl from her bed to her wheelchair. They assisted her into her wheelchair. Then, rather than bring her out to an area where she could be kept under observation, she was left unattended in her room. Shortly after being left in the room, the resident attempted to get up unassisted, and fell. She was brought to the emergency room, where x-rays showed that she had fractured her left hip – the same one which had been broken before.
The obvious cause of this nursing home fall and the injury sustained by this resident was the failure of the aide to care out the care plan. The resident was left unattended in her room in her wheelchair. This was a violation of the care plan, and the Director of Nursing conceded as much to the state surveyor. For her part, the aide told the state surveyor that she did not know that the resident needed to be supervised.
In situations such as this, where the staff cannot take the time to access readily available information to know how to properly care for a resident, this is a strong indicator that this is an understaffed nursing home. 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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