IDPH has cited and fined Red Bud Regional Care Center nursing home after a resident there fell after getting out of bed to shut the lights off because the staff did not respond to her call light.
There are a number of factors which can contribute to a resident being a fall risk. Among these are musculoskeletal, balance, or gait deficits; a history of falls; and poor safety awareness. When the resident is at risk for falling, then a fall prevention care plan must be developed and implemented. Well-constructed fall prevention care plans will generally include as elements of it anticipating the resident’s needs and promptly responding to call lights. The reason that these are commonly included in the fall prevention care plan is so that residents don’t get up unassisted when they actually need help with walking or transferring.
The resident at issue had been admitted to the nursing home for rehabilitation after a fall at home in which she broke her clavicle and her left hip. She was considered a fall risk due to poor balance, a weak gait, her history of falls, and poor safety awareness.
On the night of this nursing home fall, the resident had been put to bed. Normally, she liked the lights off when went to bed, but for whatever reason the staff left them on when they left the the room. She activated her call light to have the staff turn the lights off, but no one responded for a half hour. Tired of waiting, she got her walker went over to turn the lights off herself, and as she turned to head back to bed, she lost her balance and fell to the floor. She called for the staff to come help her, but when no one responded for over 20 minutes, she called her son with her cell phone, who in turn called the nurse’s station. The staff then went to the room and found the resident on the floor.
She was brought to the hospital where she was diagnosed with a femoral neck fracture. This is the bridge of bone that connects the femur (or thigh bone) to the ball of the hip. Even though it is described as a fracture of the femur, it is really a fractured hip. Since this was the same hip that she had broken earlier, this will undoubtedly be a complicated recovery from this injury which may leave her with additional mobility deficits.
This is case where simple failures of care led to a significant injury. Had the lights been shit off when the staff left the room (that would be an example of anticipating the resident’s needs), the resident would not have been up. Had the staff responded to the call light, the resident would not have been up. Often in a nursing home setting, these simple breakdowns in the delivery of care lead to horrific results.
When we investigate this kind of case where the use of the call light is at issue, one step we take is to find out what make and model the call light system was. Many call light systems record data regarding the time the call light was sounded until when it was shut off. This can provide really accurate data as to how long the call light had gone unanswered for any particular event. Past that, data can usually be obtained for that resident over the course of the admission, for the resident’s room, for the hall she lived on, or for the facility itself. If the data shows that the staff frequently left residents waiting for extended periods of time, this is essentially trains the residents that no one is coming for them when they sound the call light, reducing the chances that they will wait for assistance. This increases the risk of falls and catastrophic injury, such as broken hips or brain bleeds.
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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