IDPH has cited and fined Aperion Care Fairfield nursing home after a resident there fell from her wheelchair, suffered a broken leg, and then had the fracture go untreated for two weeks.
The resident at issue was wheelchair-bound and suffered from advanced dementia. There was an order in place for the use of a seat belt to prevent her from sliding out of the chair. This is in itself unusual because a seat belt is a form of restraint, and the use of restraints are discouraged in the nursing home industry for a wide variety of reasons. However, a restraints can be used in some very limited circumstances, and then only after a doctor’s order is obtained and informed consent is given by the resident or their surrogate decision-maker. Once the use of a restraint is authorized, the way in which it used must be carefully followed.
The intended purpose of the seat belt was to keep the resident from falling out of the chair. To get the order for the use of this restraint, this had to be a recurrent risk to the health and well-being of the resident and its use had to be necessary. When the use of a restraint is authorized by physician order, that order should be followed by the nursing home staff.
This nursing home fall occurred when the resident was in the dining room seated in her wheelchair. The seat belt for the seat belt for the wheelchair was not on. The resident fell forward out of the wheelchair, and as she did so, she reached forward and grabbed onto a tablecloth. As she did so, she pulled the table cloth down as well as a television set which was placed on top of the tablecloth. The television set landed on the resident’s leg.
The aides in the dining room responded right away and lifted the television set off the resident and helped her to her wheelchair right away rather than summoning a nurse to assess the resident. One of the aides reported the fall to the nurse assigned to the resident, but apparently failed to mention that the television set landed on the resident. When the nurse checked on the resident, she was already in her wheelchair with no obvious signs of injury and given that the nurse was under the impression that this was a “simple fall,” no detailed assessment was done of the resident’s condition nor was the fact of the fall documented in the resident chart or was a 72-hour fall watch started. There was also no physician notification of the fall.
Over the next several days, the condition of the resident obviously declined. She remained in bed curled up in a fetal position and was resistive to staff moving her, comforting her, or otherwise trying to care for her. She began to experience vomiting which is something that the doctor was notified about as well as the change in behaviors, but was not told about the occurrence of the fall.
Two weeks after the fall, the during the administration morning meeting the topic of the resident’s decline was mentioned. The medical records custodian mentioned that she had heard one of the staff members mention that the resident had a fall. The administrator told the state surveyor that this was the first time that he had heard that there was a fall. He instructed the nursing staff to obtain an order from the doctor for x-rays which showed that the resident had a fractured femur. She was brought to the local emergency room before being transferred to a medical center where she underwent surgery for the fracture.
There are a number of shortcomings in the care that this resident was provided:
- While restraints are disfavored in the long term care industry, they can be used when they are necessary and orders for their use are obtained. This resident had an order in place for a seat belt, and this order was obtained in order to prevent falls out of the wheelchair. The seat belt was not on at the time of the accident, and as a result the kind of nursing home fall that the seat belt was intended to prevent occurred.
- The aides moved the resident after the fall without getting cleared by the nursing staff. It is the role of the nurse to check a resident for injury and moving a resident without being cleared poses a grave risk to the safety of the resident. Here, the resident was in the wheelchair when the nurse assessed the resident. It appears from the citation that the nurse did not realize the nature of the fall, contributing the inadequate post-fall assessment.
- The nurse failed to follow up properly on the fall that occurred. It was never documented in the resident chart, the family was not notified that it had occurred, and the doctor was not informed of the fall. These are all steps that must be taken following a fall. Further, at most facilities, after a fall, the resident is placed on a 72-hour fall watch during which the nursing staff should be monitoring for the delayed onset of signs of injury, such as a brain bleed or pain associated with fractures. The failure to start a 72-hour fall watch doubtless contributed to the long delay in obtaining care for the fractures.
- The resident’s pain and injuries went without proper treatment. Subjecting a resident to unnecessary pain for that length of time is simply a form of nursing home abuse.
This series of failure in the care point to an understaffed nursing home and a poorly trained staff. Sadly failing to have enough staff and invest in staff training are hallmarks 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. 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: