IDPH has cited and fined Goldwater Care Bloomington after a resident experienced multiple falls, resulting in facial bruising and a distal femur fracture.
Falls are a special area of focus in the care of nursing home residents, in part because the occurrence of a fall tends to beget more falls and because the injuries sustained in falls have such a negative impact on the health, well-being, and quality of life of nursing home residents. Nursing homes use a number of different tools to assess a resident’s fall risk, but three major factors in determining a resident’s fall risk are: (1) whether the resident has a history of falls, (2) any type of gait or musculoskeletal weakness of dysfunction, and (3) any type of cognitive impairment or lack of safety awareness which makes it less likely that a resident will understand or follow instructions for their own safety or make good decisions regarding their own safety.
When a resident is at risk for falls, a fall prevention care plan is required. A fall prevention care plan sets forth a series of steps that the staff will take on a day-to-day, shift-to-shift basis to prevent falls.
The first nursing home fall occurred when the resident in question was in the restroom with a CNA. The resident was reaching for the sink when she slipped out of her wheelchair and hit her face on the sink, resulting in a bloody nose and bruising to the face. The second fall occurred nine days later, when the resident was found on the floor after reaching for her book, falling face forward from her wheelchair.
This second fall resulted in a distal femur fracture, a trip to the emergency room and an operative procedure to treat the injury.
There were a number of shortcomings in the care of this resident which contributed to the serious injury that she suffered. The first involved the fact that three days elapsed after the first fall before the IDT (Inter-Disciplinary Team) met to discuss the incident and begin to put in place improvements to the care plan in an effort to prevent future falls.
Once they did meet, a health status note mentions that the resident’s care plan had been updated and a seatbelt or chest harness had been ordered. This was to offer the resident additional support to help prevent the resident sliding out of the wheelchair. Unfortunately it did not arrive before the second, more serious fall occurred.
The second significant shortcoming in care was the fact that while the health status note mentions that there was an update to the care plan, the investigator was unable to find any update in the care plan nor any documentation or interventions addressing either of the falls in the plan. As far as the care plan was concerned it was as if the falls had never occurred.
This lack of documentation meant that no interventions were put in place after the first fall. One can only imagine that if fall interventions had been put in place, the second, and more serious fall, might have been prevented.
When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark of the nursing home business model.
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. 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.