IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there suffered a broken leg in a fall while getting up from the toilet.
Falls are a major source of concern in the long-term care industry. Falls are associated with increased mortality rates, steep declines in the quality of life when there is significant injury, and increased risk of falls in the future. For these reasons, and because of the requirements of federal regulations, fall risk is a specific area of focus in the care planning process.
When fall risk assessments are done, the nursing home will use its assessment tool to evaluate the resident’s fall risk. Two factors that are in in all well-done fall risk assessment tools are (1) some form of gat/balance/musculoskeletal dysfunction and (2) some form of cognitive impairment such as intermittent or constant confusion, dementia, poor safety awareness or judgment, and/or impulsivity. These combine to make the resident a fall risk because the physical issues leave the resident at risk for falls or loss of balance and the cognitive deficits increase the chances that the resident will not follow instructions, ask for assistance, or make good decisions for their own safety.
This resident had many of the factors that made her a fall risk. Her Minimum Data Set (MDS) indicated that the resident had moderate cognitive impairments, that she required extensive assist of staff with transfers, toileting, and personal hygiene, and that she was unsteady when rising from a seated to standing position and was only able to stabilize with staff assistance. The resident had a known history of attempting to rise from the toilet unassisted – something which could result ion a fall.
At the time of this nursing home fall, the facility had in place a policy which stated residents who are i9dentified as being at risk for falls if left unattended on the toilet should not be left unattended while on the toilet.
On the day that the fall occurred, the resident was brought to the toilet by an aide who then left the resident to go get hair rollers. While she was doing that the resident attempted to rise from the toilet unassisted and fell. She was brought to the hospital where a broken femur was diagnosed.
This is a resident who was at risk for just this kind of fall based on the documented findings of cognitive impairments and difficulty with standing from a seated position – all documented on her MDS, as well her known history of attempting to get up unassisted from the toilet. Based upon prevailing standards pf practice as well as the facility’s own policy, this resident should not have been left unattended. The administration of the nursing home agreed with this, writing the aide up.
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