IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there fell and suffered a fractured hip, resulting in his wrongful death two days later.
The care planning process is the basic tool for delivering routine care in a nursing home setting. There are six basic steps to the care planning process: (1) assessment of the risks to the health and well-being of the resident, (2) development of a care plan which spells out various steps or interventions that are to be taken on a day-to-day, shift-to-shift basis to address those risks and assigning those measures to staff members, (3) communicating the care plan to the staff charged with carrying it out, (4) actual implementation of the care plan, (5) evaluation of the effectiveness of the care plan, and (6) revision of the care plan if it proves in effective in practice or if there are changes in the condition of the resident.
Successful care planning requires all six of these steps, but one thing that is actually required by the federal regulations is that the interventions in the care plan be individualized and suited for the resident. In other words, the steps in the care plan itself should be tailored to the needs of the resident.
The resident involved was recognized as a fall risk. He had a history of falls, had document cognitive impairments with severely impaired decision-making. He used a wheelchair at times and required staff assistance for bed mobility, transfers, and locomotion. The staff was aware that the resident would frequently ambulate within his room and transfer himself. The fall prevention care plan called for assistance as needed when the resident was not feeling well or was weak or dizzy and as needed with change of condition. It further included educating the resident to lock his wheelchair and to ask staff for assistance.
Two days prior to the fall, the resident had been transported to the local hospital because he was drooling, lethargic and not acting appropriately. He was sent back to the nursing home the same day. The following day he was having shortness of breath and below-normal oxygen saturation levels.
On the day of this nursing home fall, the resident got out of bed unassisted at 8:00 a.m. to adjust his pants. In doing so, he lost his balance and fell to the ground, suffering a fractured left hip. Sadly, for persons in this age cohort, hip fractures carry a high mortality rate, and this gentleman was one of those for whom a hip fracture proved fatal. According to the coroner, the fall and hip fracture was one of the causes of this resident’s death.
There are a number of shortcomings with the care that this resident received. First, he was a known fall risk and his behavior of walking and transferring himself in his own room was well-known to the staff. This was a resident for whom walking in his room was a risky endeavor, and to reduce the risk of this kind of fall, he should have been kept in areas where he could be easily observed such as in the dining room or by the nurse’s station. Secondly, his care needs required reassessment after the hospital visit two days before in terms of his strength and cognitive status. Due to this change he likely required closer observation than usual. Third, the steps in the care plan were not suitable. As the nurse appropriately told the state surveyor, “I do not think educating a confused resident to ask for assistance is a good intervention for a fall.” This is completely accurate – one of the reasons that cognitive impairments is a contributing factor for fall risk is that the resident cannot be counted upon to make good decisions for his own safety.
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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