IDPH has cited and fined Niles Nursing & Rehabilitation Center nursing home after a resident there suffered a brain bleed in a fall which resulted in her death.
The care planning process is the fundamental method by which the routine care that is provided to residents in nursing homes is provided. The whole point of the process is to make sure that the needed care is delivered to residents on a day-to-day, shift-to-shift basis. In order to have an effective care plan, the components of it need to be reduced to writing and communicated to the staff charged with carrying it out. Without this, the delivery of care is to a greater or lesser extent left to random chance, and that is never acceptable.
Unfortunately, that is what happened with this resident – and with disastrous results.
The resident at issue had been assessed repeatedly as being at high risk for falls due to ataxia (a degenerative condition of the nervous system which impacts balance) , muscle weakness, poor cognition, and poor safety awareness, among other issues. She also had a history of falls, and it is well-recognized that with nursing home residents, having a fall predisposes them to having additional falls. There was a fall prevention care plan and the staff was expected to check on her frequently even though this was something that was not incorporated into the care plan.
On the day of the accident, the resident was left in the dining room unattended with a group of other residents. This was confirmed during the IDPH investigation when the Director of Nursing admitted to the state surveyor that she checked the video surveillance tape and saw that there was no staff in the dining room at the time of this nursing home fall. The resident stood up from her wheelchair, but then lost her balance and fell backwards, striking her head on the floor.
The resident was sent to the emergency room where she was diagnosed with a subdural hematoma, a form of brain bleed. They decided to not proceed with surgery and she was discharged back to the nursing home where she died twelve days later. Cause of death per the death certificate was subdural hematoma caused by the fall.
This situation is one which demonstrates what happens when essential steps needed to keep a resident safe are not incorporated into the care plan – they are not done on a consistent basis. This was a resident who needed close supervision because of her impulsiveness, poor judgment for her own safety, and poor balance. She simply could not be counted on to do the things she needed to do on her own to keep her safe. However, keeping her closely supervised was not incorporated into her care plan, and as a result she was left unattended in the dining room and fell while trying to get up out of her wheelchair.
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:
Generations Oakton Pavilion resident falls, fractures hip
Short staffing leads to fall at Warren Barr North Shore
Wheelchair accident at Avanti Wellness
Warren Park Health & Living Center resident suffers brain bleed in fall in stairwell
Alden Valley Ridge resident breaks leg in fall
Resident fractures leg due to unsafe transfer at Ascension Nazarethville in Des Plaines
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