IDPH has cited and fined Walker Nursing Home in Virginia, Illinois after a resident suffer a broken tibia and fibula in a fall which required surgical repair. The amount of the fine was $25,000 which is one of the highest that can be imposed against a nursing home.
The details of the citation are scarce, but the resident was assessed as being at high risk for falls due to severe cognitive impairments, poor impulse control, musculoskeletal weakness, and a history of falls. There was a fall prevention care plan which included making sure that the resident had proper-fitting footwear. The resident experienced a nursing home fall on July 12. Following this fall, the nursing home conducted an investigation and concluded that poorly fitting shoes was one of the causes of the fall.
The resident had a second fall on August 29. This is the fall which resulted in the fractured tibia and fibula. The nursing home investigated the cause of this nursing home fall and concluded that there were two causes. One was unlocked wheels to a bed. The other was ill-fitting footwear.
This fall shows a couple of areas where there is a breakdown in the delivery of care to this resident.
First, there are a few federal regulations relating to nursing home falls. 42 CFR Part 483.25 has two separate requirements which likely came into play in this factual scenario. The first is that the resident environment be kept as free from accident hazards as possible. Residents with poor balance frequently on furniture, railings, and so forth as aids to help them maintain their balance. When the wheels to a piece of furniture are unlocked and starts to move, elderly residents with musculoskeletal weakness and balance issues are not likely to recover their balance and a fall is the likely result. The second regulatory requirement is section 483.25 is that resident be provided with adequate supervision and assistive devices to prevent accidents. If the resident was wearing improper footwear leading up to the second fall, that raises serious issues about whether proper supervision was being provided.
Second, there is an issue with the care planning process. One of the steps in the care planning process is evaluating a care plan for effectiveness and revising it if it isn’t working. When it comes to fall prevention, the occurrence of a fall is something that should trigger the process of evaluating and revising the care plan. Having resident in proper footwear is a basic step in a fall prevention care plan. When a fall occurs and improper footwear is shown to be the culprit, specific steps to ensure the use of proper footwear is required, but it does not appear that this was the case. This is a simple measure which if taken would have helped assure the safety and well-being of this resident.
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