IDPH has cited and fined the Odd Fellow-Rebekah Home nursing home in Mattoon after a resident suffered a fatal brain bleed due a fall that occurred after she was left unattended while going to the bathroom.
The resident involved had a complex medical history, including diagnoses of atrial fibrillation, abnormalities of gait and mobility, unsteadiness on her feet, and generalized muscle weakness. The diagnosis of atrial fibrillation was significant because she received a blood thinner commonly known as Eliquis in order to prevent blood clots brought on by the atrial fibrillation. Blood thinners are obviously an important part of preventing blood clots that can lead to stroke and other cardiac and circulatory events. However, one of the risks of the use of blood thinners is the risk of internal bleeding with trauma. In particular, brain bleeds are known to occur after falls, even in the absence of a direct blow to the head.
The resident was also well-recognized as being a fall risk. Her fall risk assessment showed her to be at high risk for falls. The Minimum Data Set (MDS) completed by the nursing home staff showed that she had cognitive impairments, required staff assistance with all activities of daily living, that she was not steady during transitions and while walking, and that she needed the staff with her to stabilize her while toileting. The Minimum Data Set is a form which is completed by the staff and certified under as being an accurate statement of the care the resident requires and is receiving. The reason that is certified under oath is that it forms part of the basis by which the nursing home is paid for the care
In the week prior to the fall at issue, she two other falls. The occurrence of falls is significant because it is well-recognized in the long-term care industry that falls tend to beget more falls. After each of the two prior falls, the staff investigated the fall and determined that the first was caused by her legs becoming weak while walking and that the second was caused by a loss of balance while trying to get to the bathroom unassisted. After each, the staff checked a box for “no” on the form which read, “Independent for Toileting.” After each of the two falls, the resident fall prevention care plan was upgraded.
On the day of this nursing home fall, the aide assigned to the resident was told by another aide who had been in the resident’s room that the resident was on the toilet with clothes on. The aide went into the room and found the resident laying sideways on her bed undressed with resident’s walker turned over on the floor. The aide got the resident positioned in bed and notified the nurse.
The following morning, aides getting the resident from bed saw that the resident had a large (10.5 cm x 12 cm) bruise on her face. The nurse notified the resident’s physician. The doctor happened to be in the nursing home and upon seeing the resident ordered her sent to the emergency room for evaluation. A CT scan at the hospital showed that there was a large (22 cm), acute brain bleed. She was transferred to another hospital where she died a week later. Her cause of death, per her physician, was brain bleed due to the fall.
Following the fall, the director of nursing conducted an investigation and concluded that the cause of the fall was the resident being left unattended on the toilet and attempting to return to bed without assistance.
This was a highly preventable fall. The nursing home staff clearly recognized that she was a fall risk due to her generalized weakness. However, her cognitive impairments were a substantial barrier to her being able to make good decisions for her own safety and to heed warnings and instructions. After each of the two earlier falls (one of which happened when she was on her way to the bathroom unattended), the investigation showed that she was no independent for toileting. Nonetheless, the aide left her on the toilet on her own and left her to get off it and back to bed on her own. In short, her well-recognized care needs were not met. This led directly to her fall and death.
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