IDPH has cited and fined Charleston Rehabilitation & Health Care Center nursing home after a resident there suffered a brain bleed and a fractured hip in a fall from bed.
There are two basic means by what care the resident is to receive in a nursing home is determined. First, the are physician orders. If there is an order in place, it is the obligation of the nursing staff to execute those orders. The second is through the care planning process. In the care planning process, the nursing staff makes an assessment of the risks to the health and well-being of residents. Based on that assessment, a series of steps, or interventions, or assigned to various members of the care team to be carried out on a day-to-day, shift-to-shift basis.
The resident at issue here suffered from significant cognitive impairments and his Minimum Data Set (MDS) showed that he needed extensive assist with bed mobility, which includes changing and maintaining position within bed. He was apparently also a restless sleeper as there were physician orders in place for the use of side rails and the care plan called for placement of a body pillow on the edge of the bed as a reminder, with other pillows to be used when the body pillow was not available.
Before the day of this nursing home fall, the resident had side rails as ordered on his bed. However, he contracted covid and had to be moved to another room. When he returned, the side rails had been removed from his bed and were not re-installed. On the day of the fall, the staff heard a loud crashing sound from the resident’s room. The entered the room to find the resident laying face up next to the bed. There was no body pillow is use.
The resident was brought to the hospital where he was diagnosed as having suffered a brain bleed and a fractured right hip.
There were good fall prevention measures in place for this resident: (1) the physician-ordered side rails and (2) the use of the body pillow as incorporated into the care plan. Sadly, neither of these measures were being carried out, and as a result, the resident suffered a very preventable fall with serious injuries resulting.
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