IDPH has cited and fined PA Peterson at the Citadel nursing home in Rockford after a resident there suffered a broken neck in a fall from the toilet.
There are a number of conditions that can place a nursing home resident at risk of falling. The ones which we most commonly address are a combination of (a) some form musculoskeletal, balance, or gait dysfunction which makes walking or transferring difficult and (b) some form of cognitive impairment, poor safety awareness, or confusion which makes it difficult for the resident to follow instructions or take other steps for their own safety.
However, there are other, medical conditions which increase fall risk, all of which must be addressed in the resident’s fall prevention care plan. Among these conditions are a history of syncopal episodes or orthostatic hypotension. A syncopal episode is a sudden drop in blood pressure which causes the resident to lose consciousness and muscular control. Orthostatic hypotension is a sudden drop in blood pressure which occurs when rising from a seated or lying position which results in dizziness. Either of these can result in falls and significant injury.
The resident at issue was admitted to the nursing home for rehabilitation after a hospital admission for dizziness and a fall after having a syncopal episode. The resident’s admitting diagnoses included syncope. Less than a week after the resident was admitted to the nursing home, the resident had a syncopal episode while using the bathroom under the supervision of occupational therapy. This was reported to the nursing staff. Based on this, the nursing staff was well aware that the resident was at risk for falls due to syncope.
Until the medical causes of the syncope were brought under control, the resident’s care plan should have included steps to address the risk of injury due to falls associated with a syncopal episode. These steps should have included placing the resident in either a bed or a recliner when not under direct observation. Further when the resident was seated upright or standing, the resident would require direct supervision and assistance so that he would not experience a fall during a syncopal episode. These measures were not incorporated into the resident care plan until after the fall at issue.
This nursing home fall occurred in the morning after the resident was brought to the toilet in the morning by an aide. The aide left to attend to other residents. Due to his history of syncopal episodes the family had requested that the resident not be left on the toilet unattended. When she returned, she found the resident face down on the floor in front of the toilet with some bleeding from nose and forehead area. The resident reported to nurse that he passed out while sitting on the toilet – the very definition of a syncopal episode. The resident reported had indentations in his forehead from the tile
The resident also complained of neck pain. The usual protocol when someone complains of neck pain is to call paramedics, have them secure the neck, and have the neck cleared at the hospital. This is due the risk of serious injury that can result from moving an accident victim with a spinal injury.
The resident was helped from the floor despite his complaints of neck pain. As the day progressed, the resident began to complain of more significant neck pain. The nurse practitioner was notified of the resident’s change in condition and she ordered the resident sent to the hospital. At the first hospital, scan showed the resident had a fracture of the C2 vertebra. He was immediately transferred to another hospital where a neurosurgery team did a cervical fusion operation.
Here the staff was clearly aware that the resident had a history of syncopal episodes. It was one of the causes of his hospital admission before going to the nursing home. Further, it was one of the diagnoses included by the nurse practitioner. Occupational therapy reported to the nursing staff that he had a syncopal episode while working with them. Further, this was brought to the attention of the staff on the floor by the family who specifically requested that he not be left alone on the toilet. None of this was incorporated into the resident’s care plan at the time of his injury. This was compounded by their decision to get the resident up off the floor after his injury despite his complaints of neck pain. Given the level at which the fracture occurred, this could have had devastating consequences.
One of our basic 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:
Failure to use gait belt leads to fall and fracture at Fair Oaks Rehab in South Beloit
Fall from toilet at Alden Park Strathmoor
PA Peterson resident breaks both legs in fall
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