IDPH has cited and fined Pekin Manor nursing home after a resident there sustained a brain bleed in a fall.
Falls are a significant issue in the long term care industry because of the serious adverse effects they have on the mortality rate and overall quality of life for nursing home residents. Because of this, falls are a specific area of focus in the care planning process. There are six steps to the care planning process: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a care plan which spells out specific steps (or interventions) to be taken to address the risks to the resident’s health and well-being, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if proves to be ineffective in practice of if changes in the resident’s condition warrant it. An effective care plan is one that meets the risks of resident and are tailored to that particular resident.
When it comes to falls there is no “gold standard” risk assessment tool similar to the Braden Scale used for assessing the risk of developing bed sores. However, there are two major fall risk factors which appear in just about every well-designed fall risk assessment tool. The first of these is some form of balance or musculoskeletal dysfunction which leaves the resident at risk of falling. The second major fall risk factor is some form of cognitive deficit such as constant or intermittent confusion, dementia, forgetfulness, or general poor safety awareness or judgment. The reason that cognitive deficits contribute to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety. When the cognitive deficits are significant contributors to fall risk, the care plan should reflect this.
The resident was admitted to the nursing home as a short-term admission for rehabilitation and strengthening. Her preliminary care plan assessed her as being a fall risk. The care plan called for “call light education” as an intervention to address her fall risk. During the days that followed, the full extent of her cognitive impairments became apparent. Her Minimum Data Set (MDS), which is submitted under oath to the federal government, documented her as having severe cognitive impairments. The nursing home social worker told the state surveyor after the fall that she suffered from cognitive impairments to the point that she was unable to recognize family members. Her roommate told the state surveyor that she would forget things that she had been told five minutes earlier.
In light of this, call light education was an inadequate care plan. She simply could not be relied upon to use the call light, completely undermining that as a fall prevention strategy. Federal regulations call for residents to receive supervision and assistance as necessary to prevent accidents, and falls are a form of accident. As the extent of her cognitive impairments became apparent, her care plan should have been revised to include supervision as a primary means of fall prevention, rather than depending on her to use the call light.
On the day that this nursing home fall occurred, the resident was found on the floor of her room with bruising to the back of her head. She was sent to the emergency room where a CT scan showed that she suffered a brain bleed as a result of the fall.
Sadly, the basic step of having an adequate care plan was not taken in this case. Both her doctor and the director of nursing told the state surveyor that the care plan was not proper in light of her cognitive impairments. Without an adequate care plan, fall prevention was left to random chance.
Pointing to an inadequate care plan providers an easy answer as to why this resident fell and was injured, but the deeper question is why this happened. The real answer to that question probably relates to the management of the nursing home – the staff was so stretched and stressed that they did not have the time or ability to give this resident’s needs to the critical thought and attention they required. Unfortunately, that is typical of how nursing homes are operated. 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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