IDPH has cited and fined Monmouth Nursing Home after a resident experienced multiple falls, resulting in facial fractures and a brain bleed.
The resident at issue was admitted to the nursing home as a sort-term rehab stay after experiencing a urinary tract infection. Her medical history included general physical deconditioning and weakness, a history of falls, and cognitive impairments which affect her safety awareness.
Falls are a special area of focus in the care of nursing home residents, in part because the occurrence of a fall tends to beget more falls and because the injuries sustained in falls have such a negative impact on the health, well-being, and quality of life of nursing home residents. Nursing homes use a number of different tools to assess a resident’s fall risk, but three major factors in determining a resident’s fall risk are: (1) whether the resident has a history of falls, (2) any type of gait or musculoskeletal weakness of dysfunction, and (3) any type of cognitive impairment or lack of safety awareness which makes it less likely that a resident will understand or follow instructions for their own safety or make good decisions regarding their own safety.
When a resident is at risk for falls, a fall prevention care plan is required. A fall prevention care plan sets forth a series of steps that the staff will taken on a day-to-day, shift-to-shift basis to prevent falls.
The first nursing home fall occurred on the fourth day of her admission when the resident was attempting to go from her bed to her chair without assistance and her foot slid out from underneath her. The second fall occurred two days later when she attempted to get of her recliner. The resident was not injured in either of these falls, but the occurrence of two falls in such a short interval should have triggered some revision of the resident’s fall prevention care plan for two reasons. First, one of the truisms in the long-term care industry is that falls tend to beget more falls and the occurrence of two in such a short window should have been a warning sign that additional falls were likely. Secondly, the occurrence of the two falls in such a short period of time should have served as an indication that the fall prevention care plan not not effective and needed to be upgraded.
The third fall occurred the day after the second one. The resident was walking in the hallway unattended carrying a dish with her that she was bringing back to the kitchen. She fell, hitting her face on the floor. There was bleeding and the resident was unresponsive for several minutes. 911 was called, and the resident was sent to the emergency room. Because the resident was on blood thinners and experienced loss of consciousness, a CT scan was ordered. This showed the presence of a brain bleed as well as orbital wall and maxillary fractures. The resident was transferred to a regional trauma center for further care. There, a neurosurgical consult was obtained and the recommendation was to hold the blood thinner medications and follow up in the office. The resident was returned to the nursing home four days after the fall.
When the resident was returned to the nursing home, the plan was to place her in a room closer to the nurse’s station in order to make it easier for the nurses to monitor what the resident was doing. However, the next day the resident fell yet again – the fourth fall in less than 2 weeks. This fall occurred in the morning when the resident tried to get out of bed unassisted. Earlier that night, she had been found out of bed by the staff standing in her room, and the staff felt that she was combative and confused. The staff heard the fall and found the resident on the floor with a small know on the back of her head. Shortly after, she began to complain of severe headache and was dry heaving. The resident was sent to the local hospital where a CT scan showed that there was an increase is the size of the bleed as a well a midline shift of the brain. This is an indication of increased pressure on the brain associated with the bleeding. The resident was transferred to the regional trauma center for further care.
There were a number of shortcomings in the care of this resident which contributed to the serious injuries that she suffered. First, she was well-recognized as being a fall risk because of the history of falls, cognitive impairments, and generalized weakness. Once she experienced the two falls in the facility, the care plan should have been revised to include more frequent rounding and placing the resident at the nurse’s station during waking hours to keep the resident under easy observation. This would have likely prevented the third fall which resulted in the initial brain bleed.
Once the resident returned from the hospital, the care plan should have been upgraded to include a more aggressive schedule of rounding, especially after the resident demonstrated heightened confusion and combativeness. These behaviors should have served as an indicator to the staff that she was not likely to heed instructions and advice for her own safety. Further, use of a bed alarm was called for, but one was not employed even though that was an option at this nursing home.
In short, a series of failures in the delivery of care led to a string of falls with ever-more serious injuries to this resident.
When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark 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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