IDPH has cited and fined PA Peterson at the Citadel nursing home in Rockford after a resident broke both legs in a fall from bed.
The resident at issue was a hospice patient. She had earlier been assessed as being a high fall risk due to a history of falling, poor balance, anbd forgetting her limitations. In the days leading up to this nursing home fall, she was attempting to transfer on her own and get out of her wheelchair unassisted and telling the staff that she wanted to leave the facility. She was also suffering from a urinary tract infection which in a senior citizen population can cause increased confusion.
Two days prior to the nursing home fall at issue, she she suffered another fall from her wheelchair and sustained a laceration to her head. The fall prevention nurse was notified and recommended that the resident be given a reclining wheelchair to assist with trunk support and that she not be left in her room unattended if she was awake.
On the day of the fall, the resident was given a bath by a hospice CNA and then brought to bed. The resident was discovered on the floor with the bed in the highest position and the controller for the bed on top of the bed. She left the resident alone, unaware that the resident was supposed to not be left unattended and failed to notify other staff members.
The resident was brought to the hospital where scans showed that she had comminuted, severely angluated fractures of both femurs.
This fall demonstrates what happend when members of the care team are unaware of what needs to be done to care for the resident properly. The fall prevention nurse came up with a reasonable plan to address the resident’s fall risk after she had the fall from her wheelchair – not leaving her alone. This was necessary after she was demonstrating increased agitation and poor judgment for her own safety, especially in light of her urinary tract infection. It is unlcear whether this was formally included in her fall prevention care plan, but one basic step to delivering quality care in a nursing home setting is making sure that everyone knows what needs to be done. The hospice aide was not aware of the added fall prevention measures, and as a result this fall occurred.
The hospice aide is clearly that most responisble for this fall. However, federal regulations also place the responsibility on the nursing home to provide the supervision necessary to prevent accidents, including falls. This means that even though the hospice agency would have some liability for this fall, the nursing home would as well.
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