Neglected Resident at Bella Terra Schaumburg Falls In Dining Hall, Fractures Hip

IDPH has cited and fined Bella Terra Schaumburg nursing home after a resident there suffered a hip fracture in a fall in the dining room.

Falls are a major concern in the long-term care industry because of the serious negative effects they have on mortality and the long-term quality of life for nursing home residents.  Because of this, they are a regular focus in the care planning process.

Nursing homes use a variety of tools to assess a resident’s fall risk.  Some of the major factors are a recent history of falls, as it is well-recognized in the long-term care industry that falls tend to beget additional falls; balance, gait, or musculoskeletal dysfunction; and some form of cognitive impairment, dementia, constant or intermittent confusion, or general poor judgment or awareness for one’s own safety or limitations.  The cognitive impairment factor is crucial because this means that a resident cannot be counted on to follow instructions or to make good judgments or decisions for his or her own safety.

Federal regulations pertaining to falls in nursing homes provide that residents must receive supervision and assistance necessary to prevent accidents.  Falls are considered accidents under the regulations.

Close supervision of the resident is a mainstay of any fall prevention strategy in a nursing home.  One of the common ways of providing supervision to residents is to gather them in areas where several residents who require supervision can all be watched at the same time by a limited number of staff people.  Common examples of this would be to gather residents in an activity room, near the nurse’s station, or in the dining room.

The resident at issue had a MDS (minimum Data Set) assessment that  showed he had impaired cognition and required extensive staff assistance for all activities like bed mobility, transfers, and using the toilet. The MDS indicated he was extremely unsteady on his feet and only able to stabilize himself with full staff assistance when moving from seated to standing, walking, getting on and off the toilet, and during transfers. The assessment also documented right-sided paralysis as a result of a previous stroke. Additionally, it showed the resident had impaired decision-making capacity and required complete staff support for daily choices due to his cognitive issues.

He was categorized as having high risk for falls due to these multiple physical and functional limitations and dependencies requiring assistance.

About a week before the fall that resulted in the injury, the resident had a fall in his room while attempting to get out of his wheelchair without the assistance of staff.  After this fall, the resident’s fall prevention care plan was updated to “offer toileting to the resident upon rising in the morning, before and after each meal and at bedtime.”

On the day of this nursing home fall, the resident was last seen unattended, self-propelling his wheelchair in the dining room of the nursing facility. His assigned nursing assistant was busy caring for another resident at the time and was not present to supervise him. At some point, the resident stood up from his chair in the dining room and subsequently lost his balance. A staff member witnessing from across the room saw him fall to the floor, landing on his right side. However, the staff member was too far away to reach him in time to assist or prevent the fall.

Immediately after the fall, the resident complained of significant pain in his right hip area. He was kept immobilized by staff and emergency medical services were called. He was transported to the hospital where he was admitted and diagnosed with a right acute femoral neck fracture requiring urgent surgical intervention.

Critically, Interviews with nursing staff later revealed that the resident had not been assisted to the bathroom following his dinner meal, which was supposed to be an implemented intervention for his toileting needs after the fall less than a week earlier.

Also, the dining room was understaffed.  The lone CNA staff member in the dining room at the time of the fall told the investigator that “there were so many residents in the dining room at that time who were at high risk for falls and could not watch them all.” 

Other staff members concurred that there should have been two staff members present for supervision and assistance in the dining hall instead of just one.

This is a case where the extent to which dementia/confusion plays into fall risk is clearly demonstrated.  The resident was not able to walk independently – he used a wheelchair as a matter of routine – but because of his cognitive impairment, he thought that it was appropriate for him to try to get up on his own when he was clearly not able to do so safely.  This is why close supervision of residents who have cognitive impairments is so crucial – because they cannot be relied upon to follow instructions or make good decisions for their own safety. 

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.