IDPH has cited and fined Hope Creek Nursing & Rehabilitation nursing home in East Moline after a resident there suffered a fractured hip after being left unattended on the toilet.
The resident at issue was recognized as being at high risk for falls, based on a number of factors. These included a history of falls (4 in the six months prior to this nursing home fall), severe cognitive impairments, and musculoskeletal weakness and dysfunction. The overall fall risk was significant enough that she was provided a helmet to wear to prevent brain bleeds in the event that there was a fall. Her fall prevention care plan included the general step of anticipating and meeting the resident’s needs.
However, the resident’s Minimum Data Set (MDS) contained a much more specific set of steps that were to be taken to prevent falls. The Minimum Data Set is submitted to the federal government signed under oath by the nursing home staff and it details what care is in fact being provided to the resident. That affirmation serves as part of the basis by which the nursing home is reimbursed for the care that it provides to the resident. If the nursing home is certifying to the federal government that it is providing a certain level of care to the resident, then that care must be provided. For this resident, the nursing home certified that it was providing two-person assist with toileting.
On the day of this nursing home fall, the resident was brought to the bathroom and seated on the toilet by a single aide who then left the resident unattended. The resident fell from the toilet. When discovered by the staff, she complained of left hip pain. She was brought to the hospital where a CT scan showed that she suffered a fractured hip.
When interviewed by the state surveyor, the MDS Coordinator confirmed that the resident was a two-person assist for toileting, and that the resident should never have been left alone on the toilet. The nurse assigned to the resident also confirmed that the resident should not have been left alone on the toilet due to her being a high fall risk and due to her impulsivity and that fact that the resident was wearing a helmet should have served as a clue to the aide.
The nursing home here clearly identified that the resident was a fall risk and arrived at the appropriate level care that this resident required for toileting. However, that level of care was not provided. While the resident required the assistance of two with toileting, she was brought to the bathroom by a single aide who then left her completely unattended.
The fact that so many shortcuts were taken in the care of this resident raises serious questions as whether this was an understaffed nursing home. Nursing homes are required to have enough properly trained staff on hand to meet the care needs of residents on a 24/7 basis. Sadly, understaffing a nursing home is a feature, not a bug in 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.
Other blog posts of interest: