IDPH has cited and fined Pittsfield Manor nursing home after a resident from that facility suffered a fatal brain bleed while being transported to a dental appointment.
There are times when nursing home residents need to obtain services which cannot be offered in the facility. At times, family will take them, but when the nursing home takes on the role of transporting them to the outside appointment, the steps necessary to assure the safety of the residents must continue to be taken and the staff charged with handling the resident while outside the facility must be advised of the steps needed to assure the safety of the resident. Falls are a particular risk outside the doors of the facility as residents deal with busier and less familiar circumstances in an environment which is not designed to assure their safety.
This particular resident had long been assessed as being a fall risk on the standardized fall risk assessment tool used at this nursing home. She also had a history of multiple falls and one thing that we know is that falls tend to beget additional falls. She also had a diagnosis of Alzheimer’s which is of course a progressive disease. The last Minimum Data Set completed prior to the incident at issue indicated that she needed supervision of one with ambulation. However, she also had two additional falls after that , but there is no indication that the fall prevention care plan was updated following those two falls. Staff interviewed by the state surveyor indicated that the resident complained of increased dizziness and needing to have hand held while she was walking.
On the day of the accident, the resident had a dental appointment. She was going to be driven to the appointment by a staff member in the facility van. When the aide who was driving the van picked the resident up, she was told by another aide that the resident help climbing the steps to the van and needed help with the seat belt. The aide was not told that the resident had a history of falls or that she needed supervision or assistance with walking.
When they arrived at the dental office, the aide stopped the van in front of the entrance and helped the resident unbuckle her seat belt and get out of the van. She then left the resident unattended while she went to park the van. However, before she could pull away, the resident fell to the ground. The aide got out of the van and saw that the resident was bleeding from the head. She called 911 to have the resident brought to the emergency room. In the emergency room, she was diagnosed with a skull fracture and brain bleed. It was decided that she was not a good candidate for surgery and died three days later as a consequence of the fall.
Continuity of care is a critical issue when addressing the care needs of nursing home residents. This is why there are written care plans – to help ensure that the resident receives the care that they need on a day-to-day, shirt-to-shift basis. Here, the aide taking the resident to her dental appointment was not provided with the information she needed to help prevent this kind of fall.
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