IDPH has cited and fined Symphony of Palos Park nursing home after a resident there suffered a brain bleed as a result of a fall which occurred due to him being left unattended while seated on a toilet.
Federal regulations pertaining to nursing home falls call for residents to receive supervision and assistance as needed to prevent accidents. Falls are a form of accident, and the regulations require nursing homes to take the required measures to prevent this kind of accidental injury. How does the staff know what has to be done to prevent falls? The basic answer to that is the care planning process.
During the care planning process, there is an assessment done of the risks to the health and well-being of the resident. This results in a care plan being developed which sets forth a specific set of measure which staff members are assigned to carry out on a day-to-day, shift-to-shift basis. The care plan must be communicated to the staff charged with carrying it out and then it must actually be implemented. Finally, its effectiveness must be evaluated on an ongoing basis and then revised if there are changes in the resident’s needs or it proves to be ineffective in practice.
The resident at issue had a number of medical conditions which placed him at risk for falls, including a history of epilepsy, cognitive impairments, and generalized weakness. The resident was assessed on multiple occasions using the facility’s fall risk assessment tool which scored him consistently as 18 or higher. On the fall risk assessment tool used at this nursing home, any score 10 or higher indicated a high risk of falls and required that the resident be placed in the “red leaf” fall prevention program. Staff were trained that residents who were in the red leaf program were not to be left unattended on toilets.
On the day of this nursing home fall, the resident was brought to the toilet by an aide. The aide who brought the resident to the toilet then left to get a beverage for the resident, telling him to pull the call light when he was finished. When the aide returned to the room, she found the aide on the floor. The resident was sent to the hospital where he was diagnosed as suffering from a brain bleed.
There was clearly a break down in the care that this resident received. He was assessed as a fall risk and the nursing home had a reasonable procedure in place to address that fall risk: that residents should not be left unattended while seated on a toilet. One reason for this is that it actually requires a significant amount of trunk control to maintain position on the toilet. Unfortunately, either the risk level for this resident was not communicated to the aide involved, or she was not properly trained on the red leaf fall prevention program. In either event, this breakdown in the care led to this resident’s fall and injury.
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