IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center nursing home in Chicago Heights after a resident there suffered a fractured leg after falling eight times in just over a year, with seven of the falls (including the last) being caused by her attempting to go to the bathroom unassisted.
One of the common situations where falls occur in nursing homes is when the resident attempts to go to the bathroom. Nursing home residents are adults and when they are able to control their bowel and bladder and have sufficient cognitive wherewithal to recognize this, the desire to maintain their dignity takes over and they will attempt to make it to the bathroom unassisted, often leading to disastrous outcomes.
Before the fall at issue, this resident had 8 prior falls in just over a year’s time. After each fall, the staff did the right thing and performed a root cause analysis in an effort to determine why the fall occurred. When there is a root cause found, then there should be changes to the fall prevention care plan to take steps to prevent further falls. The net result of the root cause analysis for 6 of the prior falls is that the root cause was the resident attempting to go to the bathroom unassisted. Further to the nursing home’s credit, the care plan was upgraded five times to include getting a urinalysis, use of floor mats, a referral to physical therapy, rounding every 2 hours, and then finally rounding frequently and keeping resident in area where she could be supervised.
On the day of this nursing home fall, the resident was attempting to go to the bathroom unassisted and fell again. This time, she suffered a fracture of the femur which resulted in her being wheelchair bound.
The nursing home did many things right in the care of this resident. She was clearly a fall risk and was treated as such. When she sustained falls, there was an effort made to determine the cause of those falls and to try to prevent further falls. However, there was a common theme among almost all the falls in that she was attempting to go to the bathroom unassisted. One means of addressing the behavior would be to put the resident on a toileting schedule. This would involve the staff tracking the resident’s bathroom habits over period of several days so that the patterns could be discovered, and once those are identified, the staff would be scheduled to bring the resident to the bathroom when the need was expected. This was never tried for this resident, leading to repeat falls with changes in the care plan of dubious value.
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.
Other blog posts of interest: