The client was a long-term nursing home resident due to advanced dementia which was a consequence of a stroke. She was admitted to the defendant nursing home after having previously been a resident at two other nursing homes. In the two previous nursing home, she was properly assessed as a fall risk due to a number of factors, including musculoskeletal weakness and dementia. The fall prevention care plan at each of the two nursing homes she had been in before included the use of a low bed, floor mats, and a bed alarm.
She entered the defendant nursing home after a hospital admission for a urinary tract infection and dehydration. At this nursing home, she was properly assessed as a fall risk, but the use of a bed alarm was never a part of her care plan and the use of a low bed and floor mats was only included in a preliminary care plan which was discontinued after she was moved to a different wing of the nursing home.
The client fell after getting out of bed after apparently spilling water on herself. She was discovered on the floor and was taken to the hospital where she was diagnosed as having suffered a fractured hip. She underwent surgery for the fractured hip and then returned to the nursing home for further physical therapy, but never regained any significant ability to walk.
She died approximately five and a half months after the fall due to unrelated causes.