IDPH has cited and fined Promedica Skilled Homewood nursing home after a resident there suffered a fractured hip in a fall.
Federal regulations pertaining to falls in nursing homes provide that residents are entitled to receive supervision and assistive devices necessary to prevent accidents. Falls are a type of accident.
Because falls are addressed in the regulations this way and because falls have such a detrimental affect on the quality of life and well being of nursing home residents, they are a specific point of focus in the the care planning process. There are a six basic 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 written care plan, (3) communication of the contents of the care plan to those members of the care team charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan if it proves to be ineffective in practice or if the resident’s care needs change.
Nursing homes use various tools to assess a resident’s fall risk, but there are two main factors that feed into fall risk: (1) some form of musculoskeletal weakness or gait, strength, or balance dysfunction and (2) intermittent or constant confusion, dementia, or general poor safety awareness or judgment. These type of cognitive deficits feed into fall risk because the resident cannot be counted on to follow instruction or make good decisions for their own safety. A third, important risk factor is the occurrence of falls in the recent past, as it is well-recognized in the long-term care industry that falls tend to beget additional falls.
The resident at issue here was one who was clearly at risk for falls – she had well-documented musculoskeletal strength deficits, had significant cognitive deficits, and had another fall just days before the one at issue here. Further, on the day of this fall, she was telling the staff that she wanted to leave.
The fall prevention care plan did include a number of interventions or steps intended to prevent falls, but none of them specifically addressed the issue of supervision of the resident. Further, when asked by the state surveyor what steps were in place to prevent falls for this resident, the staff was unable to9 explain what interventions were actually in place. For a care plan to work, it must have steps which are specifically tailored for the resident and the staff must know what those steps are. Unless this is true, the staff is left to improvise what care is being provided to the resident where the care plan process is designed to provide the necessary care is a systematic, routine manner. Poor care plans lead to poor outcomes, and that was the case here.
On the night of this nursing home fall, the resident was given dinner and placed in bed by an aide who left the resident in her room with the TV on. Normally, a sitter would be present, but the sitter was a no-show the night of this fall. There was no provision for that added level of supervision, especially in light of the resident’s earlier comments that evening that she wanted to leave
The aide left to provide care to other residents. While she was providing care to other residents, she was notified that the resident had fallen and was in the hallway. The resident had apparently left her room by the nurse’s station and walked halfway down the hallway before her legs gave out from her, as had happened in her earlier fall and as has been seen during physical therapy earlier. The resident was brought to the hospital where she was diagnosed with a fractured hip.
There were a number of shortcoming in the care that this resident received. First the care plan did not provide for the regular, systematic supervision and observation that was necessary for a resident who this set of known behaviors and risks. Second, the fact that this resident had been verbalizing a desire to leave the nursing home was a warning sign that she was likely to get up and try to act on that, but nothing was done to mitigate the risks that were present that night. Third, the sitter who was a regular part of the care team was not present. Fourth, even minimal supervision was not provided as this resident was able to get up out of bed, walk out of her room, and then go halfway down the hallway before she was discovered – to say nothing of how long she was on the floor before she was actually discovered.
When a nursing home is unable to provide residents with the necessary supervision, that is a sign that this is likely an understaffed nursing home. Unfortunately, short-staffing a nursing home is a basic part of the nursing home business model. 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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