IDPH has cited and fined Accolade of Pontiac nursing home after a resident there was left unsupervised and fell, sustaining multiple fractures.
There are a number of factors which are considered risk factors for residents experiencing a nursing home fall. Two of the most important are some form of musculoskeletal weakness or dysfunction and either intermittent or constant confusion or dementia. The reason that dementia or confusion is a risk factor for nursing home falls is that the resident cannot be counted on to consistently follow instructions or make good judgments for their own safety.
When a resident is at risk for falls, it is incumbent on the nursing home to develop and implement a fall prevention care plan. A proper fall prevention care plan will contain steps or interventions that the members of the nursing home staff are to take on a day-to-day, shift-to-shift basis to help ensure the safety of the resident. Federal regulations regarding nursing home falls require that the nursing home to develop the care plan which would include steps to assure that the resident receives supervision and assistance necessary to prevent accidents.
The resident at issue had severe cognitive impairments and required extensive assist of two staff members with transfers. She was not able to stabilize herself while standing and had at least one other fall in the months leading up to the incident at issue. The chart notes also reflected that the staff had seen her attempting to transfer herself on multiple occasions before this incident occurred.
This resident was one who was very clearly a fall risk. She suffered from cognitive impairments and musculoskeletal issues which placed her at risk for falls. Her lack of ability to make good judgments for her own safety and follow instructions was demonstrated by the fact that she had been seen and it had been documented that she was attempting to transfer herself on multiple occasions before this incident. Finally, she had experienced at least one fall before this incident. Falls tend to beget additional falls, and are a sign that additional steps need to be taken to assure the safety of the resident.
This is a situation where not only should there have been a fall prevention care plan, but the care plan should have been revised to take additional steps to prevent falls in light of the fact that there had already been at least one fall and that the resident was being seen on an ongoing basis self-transferring when the help of two was needed.
Even though this was a situation which cried out for a fall prevention care plan, there was none. The net result of this was sadly predictable.
On the day of the accident, the resident was left unattended in the solarium. As the resident, tried to get up from her chair to move to her wheelchair, she lost her balance and fell to the ground. The resident was bleeding from the head and complained of pain in the lower extremities and hips. The resident was sent to the hospital.
At the hospital, the resident received sutures to close the head wounds. Radiographs showed that the resident suffered pelvic fractures, a fractured humerus, broken ribs, and fractures of two vertebrae in her spine. The pelvic fractures will likely leave the resident bed bound for a significant period of time, placing her at risk for developing bed sores. Rib fractures will also place her at risk for developing pneumonia. These injuries are significant in the own right but also have serious longer term implications for the health and well-being of this resident.
The failure to care plan for falls for this resident was inexcusable. She was clearly at risk for falls and was not only demonstrating behaviors which showed that risk, she also had a fall which was a warning sign of more to come. In the end, this resident will pay a real price in terms of the quality of life for this failure.
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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