IDPH has cited and fined River Bluff nursing home in Rockford after a resident there suffered multiple fractures in a fall.
Here, the resident at issue was involved in a nursing home fall in which she suffered a fractured pelvis and a fractured humerus. There was a care plan in place which called for the use of a bed alarm and a chair alarm, both of which were in place when the fall occurred. However, the resident had shut the chair alarm off when she got up to go to the bathroom and was returning from the bathroom when the fall occurred.
You may be asking yourself how this is the nursing home’s fault? The answer goes to the fundamentals of the care planning process.
Care planning is an ongoing process. It is not something that is done once and then forgotten about. There are in fact six steps to the care planning process: (1) the assessment of the risks to the health and well-being of the resident, (2) the development of a written care plan, (3) communication of the care plan to the members of the staff charged with carrying it out, (4) implementation of the care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves to be ineffective in practice or if the care needs of the resident change.
The breakdown here occurred in the sixth and final step of the care planning process. The point of the fall prevention care plan was to prevent falls by avoiding having the resident up and about unattended which was when she was at highest risk for falls. However, this resident had a known behavior of disarming the alarm when she wanted to get up on her own. The nursing home staff was aware of this, but did not make any changes even though what they were doing was being shown to be ineffective in practice.
What should have been done instead?
A chair alarm or bed alarm essentially consist of two main components: the alarm box and the alarm device. The alarm device is either a pressure-sensitive pad (which was what was in use here) or a clip which is affixed to the resident’s clothing, usually between the shoulder blades where it is difficult to remove with a short cord which goes to the alarm box. If the pressure alarm is in use, the alarm sounds when the resident gets up off the pad; if the clip is used, the alarm sounds when the cord is pulled away from the alarm box.
Here the staff placed the alarm box in easy reach of the resident who simply shut it off before getting up. This was a known behavior on the part of the resident which had been shown on a number of occasions before this nursing home fall. All that would have been required to prevent this fall would have been to modify the resident care plan to include placing the alarm box out of the reach of the resident and making sure that this was communicated to the staff charged with caring for this resident. However, due to a lack of effort and critical thought, this change was never made. A care plan which is ineffective in practice is not one that meets the care needs of the resident. Making that simple change would likely have prevented this injury.
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