IDPH has cited and fined Park Pointe Healthcare and Rehab nursing home in Morris after a resident there suffered multiple fractures due to falling down a stairwell.
The resident involved in this fall down the stairwell had a care plan for wandering. Wandering is also known as elopement in the long-term care industry and is a serious risk of harm to the resident. Residents who wander can find themselves in situations where they are faced with hazards which due to physical or cognitive limitations, they are unable to safely face or address. This resident was also a fall risk because she was wheelchair-bound and had musculoskeletal deficits as well as significant cognitive deficits.
For residents which are at risk of harm due to wandering/elopement or falls, there are a number of steps that can be taken to mitigate that risk. One of the principal steps is to keep the resident under close supervision. Doing this reduces the risk from injury for both falls and wandering, and is consistent with the requirements of federal regulations.
On the day of this nursing home fall, the staff noticed that a plastic curtain, which went to an otherwise-empty COVID unit, had been disturbed. The staff checked the rooms in the COVID unit for residents but did not find any. They returned to their own unit and discovered that the resident involved in this incident was missing.
They looked throughout the facility but were unable to locate her and returned to the COVID unit. Upon return to the COVID unit, they re-inspected all of the rooms and were unable to find the missing resident. Coming to the end of the hallway, they noticed that the door to the stairwell was closed, but the green light for alarm was flashing. This was an indication that the alarm was not armed.
The staff opened the door and found the resident down at the bottom of the stairwell, with her wheelchair two or three steps down the stairwell. She apparently had begun to fall down the stairs. The wheelchair stopped, and she was ejected from the wheelchair. An ambulance was called. The resident was brought to the hospital where she was diagnosed as having a fracture to her clavicle, as well as broken ribs.
There were two major shortcomings in the care that this resident received. First, any resident who is at risk for falls and is also known as a wanderer and at risk for elopement should be a resident who is closely supervised. The citation issued by IDPH indicates that the staff was well aware of her history of wandering and that she wandered actively throughout the facility, often looking for her husband, who is in fact, not a resident at the facility. Keeping her under close observation would have likely prevented this injury, especially given the amount of time that it would have taken her to travel that distance and open not only the door to the stairwell, but also the curtain to the COVID unit.
The other major shortcoming in the care that this resident received is that the stairwell was not secured with either a lock or an alarm. Stairwells pose a special risk of harm to nursing home residents. This is partially due to the fact that many are simply not able to negotiate them safely as well as the fact that stairwells are an area where they are out of view of the staff. Once a fall occurs in a stairwell, it is likely that the resident will endure a prolonged period of time before the fall is discovered and care for any injuries from the fall can be offered.
In this particular case, the practice at the nursing home was that the maintenance staff would check the alarms throughout the facility during weekdays, but there was no one specifically assigned to check the alarms on weekends – which is when this fall occurred. As a result, the stairwell was not secured with locks or alarm leading to the fall and injuries sustained by this resident.
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: