IDPH has cited and fined Piatt County Nursing Home after a resident there fractured a hip in a fall due to the failure of an aide to provide needed supervision and assistance.
Falls are a major issue in the long-term care industry due to the serious negative effects that they have on the mortality and quality of life of nursing home residents. Therefore, fall prevention is always a specific area of focus in the care planning process.
The care planning process begins with an assessment of the resident’s fall risk. Nursing homes use a variety of tools to assess fall risk, but one common feature in almost all tools is that (1) some form of musculoskeletal weakness, balance issue, or gait dysfunction and (2) some form of dementia, forgetfulness, intermittent or constant confusion, poor safety awareness or judgment, or some other form of cognitive impairment are major factors in weighing the resident’s fall risk. The reason that cognitive impairment contributes to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety. Where cognitive impairments are a contributing factor to fall risk, close supervision is a mainstay of fall prevention – consistent with the requirements of federal regulations.
The resident at issue was properly assessed as being a fall risk. Among the factors that made the resident a fall risk were having mobility impairments, poor balance, an unsteady gait, a history of falls, and according to the resident’s Minimum Data Set (MDS) he required extensive assist of the staff with transfers and to stabilize. On the cognitive side, he was noted to have long and short term memory problems. He further had a known history of attempting to self-transfer and forgetting to use the call light. He was considered a fall risk because of his impaired gait and forgetting and/or overestimating his limits.
On the day of this nursing home fall, the resident activated the call light for assistance to use the commode. The aide arrived to assist the resident. He provided the resident his walker and then turned and went to close the privacy curtain for the resident. As the aide was closing the privacy curtain, the resident attempted to stand using the walker. As he did so, he lost his balance and fell to the floor. The resident’s leg was rotated outward with a leg length discrepancy – obvious signs of a fractured hip.
The resident was brought to the hospital where the fractured hip was confirmed. The resident was transferred to a larger hospital where he underwent surgery to repair the fractured hip.
The facts of this fall show how quickly small failures in the care that the resident is provided can have catastrophic consequences. The aide responded to the call light (something that does not always happen) and attempted to provide the resident with a measure of dignity by closing the privacy curtain. However, he did so after providing the resident with the walker. He was not in a position to provide the resident with the needed assistance with transferring and stabilizing when he rose from the position seated at the edge of the bed. Further, he had his back turned to a resident whose known history and behaviors spoke to a need for close supervision. The Director of Nursing admitted as much, telling the state surveyor that simply closing the privacy curtain when he entered the area could have prevented this fall.
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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