IDPH has cited and fined the Sunset Home nursing home in Quincy after the failure to use a working pressure alarm led to a resident fall causing a fractured hip.
The care planning process dictates how much of the routine care in nursing home setting is delivered. It is a multi-step, multidisciplinary process which is intended to address the risks to the health and well-being of the resident in an organized, systematic way.
There are six basic steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) the development of a care plan which is intended to address those risks, (3) communication of the care plan to the members of the care team who are assigned to carry out the various elements of the care plan, (4) actual implementation of the care plan; (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.
The resident at issue here was properly assessed as being at risk of falls. She had musculoskeletal weakness and cognitive deficits – a common reason for a resident to be considered at risk for falls. She also had a history of falls, and one of the well-recognized truisms in the long-term care industry is that falls tend to beget additional falls.
Due to her fall risk, a fall prevention care plan was put into place which called for the use of a pressure alarm on her chair. A pressure alarm is a strip which is placed underneath the resident and when the pressure on the strip is released, a loud, audible alarm would sound. That sound of that alarm would serve two purposes – first to alert the staff that the resident was up without assistance and second, to remind the resident that they should not be up without assistance.
On the day of this nursing home fall, the resident was alone in her room when she decided to get up out of her chair and walked toward the door without using her walker. When she turned around to return to her chair, she lost her balance and fell to the floor, suffering a fractured hip.
Investigation into this fall revealed that although there was an alarm in place, it was not functioning. Because of that, there was no alarm that sounded when the resident got up from her chair. There were no facility policies requiring checks of the alarm on any regular basis. Of course, because the alarm was not functioning, there is no knowing how many times the resident was up unassisted and it was pure good luck that the resident did not fall. Of course, good luck is not a substitute for good care, and good luck is eventually bound to run out.
Here the resident was properly assessed as being a fall risk based on her functional and cognitive deficits. A reasonable care plan was put into place. Yet that care plan failed because the equipment being used didn’t work. A simple practice of regular checks on the pressure alarm for function would have prevented this fall and the resulting injury.
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. 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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