IDPH has cited and fined Monmouth Nursing Home after a resident there experienced eight (8) falls in a two and half month period, the last resulting in a fractured hip and a brain bleed, both of which required surgical intervention. This is the second citation that IDPH has written to this nursing home for a resident who experienced significant injuries after having multiple falls in the nursing home.
Falls are a major cause of death and diminished quality of life for nursing home residents. They are also addressed in the federal regulations, so the issue of fall prevention is a major area of focus in the long-term care industry.
Fall prevention is an area which is addressed in the care planning process. Most of the routine care that is provided in nursing homes is addressed through the care planning process. This process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.
There is no tool for assessing fall risk that is considered “gold standard” the way that the Braden scale is for assessing the risk of developing bed sores. However, any decent fall risk tool will account for the two main factors which place a resident at risk for having falls. These are: These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness. Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety. Further, it is also well-recognized that falls tend to beget additional falls – so a history of falls tends to be a precursor for additional falls.
The resident at issue had all of these factors at play. She had a history of multiple falls at home which preceded her admission to the nursing home, the last of which resulted in compression fractures in her thoracic spine. Further, she had a history of stroke with residual left-sided weakness as well as Parkinson’s. Her Minimum Data Set showed that she required assist of two staff members for most mobility activities. She further had a diagnosis of dementia and the staff recognized that she experienced confusion and was impulsive. In short, this resident was at high risk for falls and was properly assessed at the start of her admission as being at high risk for falls.
Having assessed her as being at high risk for falls, the care plan consisted of placing a “Call, Don’t Fall” sign in her room, placing the call light and personal items within reach, use of appropriate footwear and/or gripper socks, and a referral to physical therapy and occupational therapy.
Prior to the fall at issue, the resident experienced seven falls without serious injury. Additionally, there were at least three times where the staff found her transferring herself without assistance. Havin incidents such as these where there are falls and residents self-transferring without help but with no injury resulting is good luck, not good care. Reliance on good luck to assure the safety and well-being of nursing home residents is not a formula for success.
When a nursing home resident sustains a fall this should trigger some additional steps: a 72-hour fall watch, physician notification, and revision of the fall prevention care plan. Only one of these falls resulted in an updating of the care plan, and this consisted of placing additional “Call, Don’t Fall” signs within her room. Needless to say, this was not an effective measure, given her level of confusion and impulsivity.
On the morning of this nursing home fall, the resident was woken up by a nurse who was passing medication. The nurse told the resident to open her eyes because breakfast was coming soon. The nurse went on to the room next door. While she was there, she heard screaming coming from the resident’s room. The resident had gotten out of bed to go to the bathroom. Urine was found soaking the bed and the floor nearby. The resident told staff that she was trying to get clothes from her closet.
The resident was brought to the hospital where she was diagnosed with a fractured hip and a brain bleed. The fractured hip required an open reduction and internal fixation surgery, and the brain bleed required the placement of a drain to remove the blood which was putting pressure on the brain.
The overall picture here shows a failure of the nursing home to respond in an effective way to the falls that occurred. The final steps of the care planning process are evaluating the effectiveness of the care plan and revising it if it proves ineffective in practice. When a resident has seven falls and three other incidents where they were known to self-transfer when they required higher levels of assistance, this is a sign that the care plan in place was not working and the only revision made to the care plan was to place additional signage which the resident was not heeding anyway.
Further, waking the resident up and then not being in a position to assist with one of the basic needs one has upon waking up in the morning (going to the bathroom) was foolish and likely led directly to the resident’s fall and injuries. Effective rounding on residents includes not only checking on them, but assuring that their needs are met. This was clearly not done in this instance.
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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