IDPH has cited and fined Pleasant View Rehabilitation & Health Care Center in Morrison after a resident there suffered a fractured hip in a fall.
The resident at issue was admitted to the nursig home three and a half months before the fall at issue. Four days after admission, the resident was discovered lying flat on his back on the floor of his room. When a nursing home resident is discovered on the floor like this, it should be presumed to have been the result of a fall. It is well-recognized in the nursing home industry that falls tend to beget additional falls, so the resident’s fall prevention care plan was updated to include the use of a bed alarm.
Beyond the resident’s history of falls, the resident was considered a fall risk due to dementia and poor safety awareness. When a nursing home resident demonstrates either intermittent or constant confusion, this is considered a contributor to fall risk because the resident cannot be counted on to make good decisions for their own safety. This is why a measure like a bed alarm is considered an appropriate fall prevention tool – because the sounding of the alarm serves to alert the staff that the resident is up and to remind the resident that they should wait for help.
Two and half weeks before the fall, the resident’s care plan was updated to reflect that the resident had a known behavior of getting up out of bed unattended. A floor mat was added to the fall prevention care plan.
On the day of the resident’s nursing home fall, the CNA and nurse was at the nurse’s station when they heard the noise of the fall coming from the resident’s room. They went to the room immediately and found the resident lying on the floor with bleeding coming from the head,complaining of pain to the leg. The alarm had not sounded and the floor mat was away from the bed on the other side of the room.
The resident was brought to the hospital where a fractured hip was diagnosed. Surgery was performed, and the resident was returned to the nursing home. Unfortunately, the resident developed a post-operative wound infection and was receiving antibitoics for the infection at the time that the citation was issued.
The nursing home properly recognized that this resident was a fall risk. The hospital records described the resident as being nonambulatory, and the resident had a history of falls, confusion with poor safety awareness, and a known behavior of getting out of bed unattended. The steps care planned were a reasonable start to attempting to prevent further injury to this resident by calling for the use a bed alarm and floor mats. However, the bed alarm did not sound when the resident got out of bed and the floor mats were found on the other side of the room when the staff responded to the noise from the fall. A care plan not actually implemented is useless.
Past that, there were likely additional measures that could have been taken to help prevent this fall. Given that the resident had a known behavior of getting out of bed unattended, increased rounding was called for. The fall occurred at 6:20 a.m., an hour when the resident may have been waking up with an urge to use the bathroom. A toileting schedule would have likely been an effective fall prevention measure because it would have helped the staff better anticipate known behaviors of the resident which presented increased fall risk. Truly effectivecare plans actually tailored to the needs of the resident – and in fact, this is what federal regulations require.
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: