IDPH has cited and fined Ascension Saint Anne Place nursing home in Rockford after a resident there suffered a fractured hip in a fall after he was left unattended in the dining room.
Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents. Because of this, they are a regular focus in the care planning process.
Nursing homes use a variety of tools to assess a resident’s fall risk. Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations. The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.
Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents. Falls are considered accidents under the regulations.
Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home. One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people. Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.
The resident at issue was admitted to the nursing home after suffering a subdural hematoma in an earlier fall. Once at the facility, he was assessed as a fall risk due to cognitive impairments, and the need for extensive assistance of staff with transfers and the use of a wheelchair and a walker for ambulation.
After arriving in the nursing home, he had two unwitnessed falls, both of which occurred in his room. The circumstances surrounding each of these falls suggested that the resident got up from his wheelchair unassisted while left in his room alone. After the second of the two falls, the resident’s fall prevention care plan was updated to include, “resident should not be left alone in his room in his wheelchair.”
On the day of this nursing home fall, one of the nurses was looking for the resident in order to check his blood sugar. She was initially unable to locate the resident on his unit, but was able to determine that he had been brought down to the dining room. She checked his blood sugar levels and found that they were 269 (elevated blood sugar levels – above 140 – are known to be a potential cause of confusion. The nurse told the aide in the dining room to not leave the resident alone because he was a fall risk.
Shortly after this, the resident’s wife and son entered the facility. His wife went to use the public restroom while his son went to the resident’s room. On her way to the resident’s room, the wife passed by the dining room and saw a man laying on the floor and she recognized that it was her husband. He later told her that he got up because everyone else in the dining room had left, so he thought that he should too.
A dietary aide discovered that the resident was on the floor and called for help. The facility dietician responded and upon entry to the dining room discovered that there were no aides in the dining room. The nurse was summoned to the dining room and encountered the aide that she had spoken to earlier. That aide explained that he had taken another resident to their room and left the resident unattended in the dining room.
Paramedics were called to the facility and the resident was brought to the hospital where it was revealed that the resident had a fractured hip.
This is a case where the extent to which dementia/confusion plays into fall risk is clearly demonstrated. The resident was not able to walk independently – he used a walker of a wheelchair as a matter of routine – but because of his cognitive impairment, he thought that it was appropriate for him to try to leave the dining room on his own when he was clearly not able to do so safely. This is why close supervision of residents who have cognitive impairments is so crucial – because they cannot be relied upon to follow instructions or make good decisions for their own safety. Sadly, the admonition from the burse to the aide to not leave the resident alone was not followed, and this fall and injury was the result.
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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