IDPH has cited and fined Moweaqua Rehabilitation & Health Care Center nursing home after a resident there suffered a fractured hip in his second fall in as many days.
Falls are a major issue in the long-term care industry. Virtually all of the patient population in nursing are either elderly or medically frail (or both). The statistics are that a significant portion of the senior citizens who suffer hip fractures die within 6 months of the injury due to either intra-operative or post-operative complications or due to complications brought on by debility from the injury.
Because falls represent such a risk to the health and well-being of nursing home residents, they are a major focus of the care planning process. The care planning process is fundamental to the delivery of routine care in nursing homes. In short, it is a process by which the risks to the health and well-being of the resident are identified and steps, or interventions, are put into place to prevent that harm from coming to fruition.
There are six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.
When a resident experiences a fall, even one with no injury, this is a major event which requires physician notification and evaluation of the care plan. The reason the reevaluation of the care plan is required is because (a) it may not be effective, seeing as a fall just occurred and (b) it is well-recognized that falls tend to beget additional falls, so that after a fall has happened, the resident’s fall risk is actually higher than it was even the day before.
The resident at issue suffered from multiple conditions and had been assessed as a high fall risk. The first fall occurred just after 2:00 p.m. when the resident was found on the floor of his bathroom with his pants around his ankles. The cause of the fall was specified as resident actions with no further description or revision of the care plan. The next fall occurred at 7 am the following morning where the resident was again found on the floor of his bathroom. The investigation revealed that the resident was tryin to pull his pants up and lost his balance. The Director of Nursing reported to the state inspector that the resident required assistance but would refuse to use the call light at times.
The citation revealed a couple of important points. First, the staff knew that the resident had behavior of getting up without using his call light. This kind of behavior is a powerful contributor to fall risk – and to the extent that it was a known behavior, it should have been accounted for in the care plan. Second, there was apparently no consideration given to revising the care plan in light of the fall.
There were a number of steps which could have been taken to help prevent this fall. Putting the resident on amore aggressive rounding schedule would likely have been of help. The other measure would be to put the resident on a toileting schedule. How this works is that the resident’s bathroom habits are observed over a period of days, and when this happens, certain patterns are likely to emerge. Once the pattern is identified, the resident is assisted to the bathroom and through going to the bathroom. The net result of this should be that the resident is not left unattended in the bathroom.
Of note, one of the fall prevention measures taken was that a sign was placed in the resident’s room reminding him to call, not fall. Unfortunately, the resident was blind, leaving this of questionable value.
After this nursing home fall was discovered, the resident was brought to the hospital where he was diagnosed with a fractured hip and a collapsed lung.
The injuries to this resident could have been prevented with the application of critical thought about his care needs. However, nurses in a nursing home setting are often given too little opportunity for this given the demands of the residents they care for. Sadly, this is a direct result 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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