IDPH has cited and fined The Arc At Normal after a resident fell and died after attempting to toilet on his own.
There is a framework for providing the vast majority of routine care in a nursing home setting. This is referred to as the care planning process. When it is done properly, the risk of residents suffering unnecessary injuries, falls and wrongful deaths is greatly reduced. However, oftentimes there are serious deficiencies in the care-planning process which sets the stage for disaster.
When the resident in question was admitted to the nursing home, the initial assessment listed the resident at a moderate risk for falls. The only fall prevention intervention documented at that time was to make sure the call light was within reach.
The resident’s family, on the other hand, informed the admitting nurse that their loved one was a high fall risk with frequent intermittent confusion and requested that he not take the ordered Eliquis (blood thinner) due to his frequent falls and prolonged bleeding. Importantly, they communicated to the admitting nurse that their loved one be toileted at 1:00 am and 4:00 am, as that is what he was accustomed to when they were caring for him at home.
When the family was leaving the facility later that night they communicated to another nurse that they were concerned about their loved one. The nurse assured them that residents are checked on every 2 hours and toileted at those times. Further, since the resident was confused and often tried to get up, the nurse assured the family that a nurse would check on the resident every hour to see if he needed anything.
Critically, the admitting nurse never communicated to other nurses, including the night staff, that this particular resident needed to be toileted at 1:00 am and 4:00 am.
Without this critical information, tragedy struck.
An aide did stop to toilet the resident sometime between 9:00 pm and 10:00 pm, but did not return again until midnight. When the aide saw that the resident was sleeping, she decided to let the resident sleep without toileting him.
The next interaction anyone had with the resident was at 1:15 am when the aide found the resident lying face down on the floor, behind the door and bleeding from his head.
The resident was rushed to the hospital but passed that same night. Cause of death was Intracranial Hemorrhage with anticoagulant used for AFib (Atrial Fibrillation).
In this case the major breakdown in the care planning process was with communication. Once the care plan has been developed, it must be communicated to the members of the nursing home staff charged with carrying it out. This should be a simple enough process, but in practice, nurses and other staff members often have a hard time explaining how that occurs which leaves the issue in doubt as to whether the contents of the care plan are ever communicated to the people charged with doing the work.
These systemic failures are often a sign of an understaffed nursing home. Sadly, that is a basic part of the nursing home business model. 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.
