IDPH has cited and fined Odd Fellow Rebekah Home in Mattoon after a resident there was left unsupervised and fell, suffering a brain bleed.
Federal regulations pertaining to falls in nursing homes provide that resident must receive supervision and assistive devices necessary to prevent falls. Supervision is a key factor because one of the main factors that place nursing home residents at risk of falling and suffering injury is dementia, cognitive deficits, or general poor safety awareness. This leads to falls because residents with these issues cannot be counted on to follow instructions or make good decisions for their own safety.
One of the basic strategies for providing the necessary supervision is to keep the resident in an area where their actions can be easily monitored. Often this is by the nurse’s station or in a dining room or activity room where one or more staff members may be assigned to watch over several residents at once. This strategy is often incorporated into the resident’s fall prevention care plan. However for this strategy to be effective, the supervision must in fact be provided.
The resident involved was recognized as a fall risk due to a number of factors, including cognitive impairments, unsteadiness of his feet, gait and mobility abnormalities, and muscle weakness. He used a wheelchair. The resident’s Minimum Data Set (MDS) recorded that the resident was unsteady when rising from a seated to a standing position. The resident also had two falls in the first week of his admission to the nursing home, and one well-recognized fact about nursing home falls is that falls tend to beget more falls. In short, this resident was at serious risk for having a fall.
To address this risk, the staff moved the resident in his wheelchair to the nurse’s station. This was a solid strategy for fall prevention. In this facility, the nurse’s station was across the hall from the physical therapy gym, which has a window. The physical therapist on duty at the time saw the resident’s head pop into view through the window and disappear rapidly. Concerned that there was a nursing home fall, the therapist went out into the fall and saw the resident on the floor, bleeding from a wound on the head. There was no staff at the nurse’s station or anywhere nearby.
The resident was sent to a local hospital where scans showed that he had a brain bleed. He was immediately transferred to another hospital to receive a higher level of care.
Here, the staff took the right first steps in recognizing that the resident was a fall risk and bringing him to be watched at the nurse’s station. However, there was no one actually watching him when he fell. This is a violation of federal regulations which require that the resident receive supervision necessary to prevent falls. Sadly because the necessary supervision was not in fact being provided, this resident had a very predictable fall with serious injuries resulting.
This is all the more unfortunate because this is the second time in the last few months that a resident at this facility has suffered a fall with a brain bleed as a result. 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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