IDPH has cited and fined Hillsboro Rehab & Health Care Center after a resident there fell three separate times during her first week at the facility, sustaining a non-operable re-fracture of her left hip.
Falls are a major source of mortality and loss of quality of life for the nursing home population. They are also addressed in federal regulations which require that nursing home residents receive supervision and assistance necessary to prevent accidents. A fall is a form of accident. Because of this, fall prevention is a serious area of focus in the long-term care industry.
There are two major factors that make residents at risk for falls. These include (1) some form of musculoskeletal, gait, or balance dysfunction which place a resident at risk for losing balance or falling and (2) some form of cognitive impairment, dementia, confusion, or general poor safety awareness. Cognitive issues feed into fall risk because the resident cannot be counted on to follow instructions or make good decisions for their own safety.
The resident at issue was severely cognitively impaired, with behaviors such as inattention and disorganized thinking, and required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, walking in room, dressing, eating and toileting.
The day after the resident was admitted to the facility, the resident was found by a nurse on the ground at the foot of her bed, sitting on her buttocks with her left leg extended forward and right leg bent. The resident was complaining of pain and discomfort, and was transported to the ER, where all tests for injuries were negative.
The resident returned to the facility, only to fall again that same evening. This time the resident was found on the floor in front of the bathroom. She was lying on her right arm, complaining of right shoulder, back and hip pain. Before returning to the ER a second time in one day, a nurse at the facility spoke with the ER doctor. He stressed that he was unable to believe that the resident had fallen a second time, since he had given orders that upon returning to the facility the resident was to receive 1:1 care. This refers to a specialized level of care provided in nursing homes where one caregiver is assigned to provide individualized care to a single resident.
The third fall occurred approximately five days later, with the resident found on the floor near her overturned commode. This fall resulted in another trip to the ER and a diagnosis of a non-operable re-fracture of the left hip.
The citation mentions several interviews with nurses that try to explain how the order for 1:1 care from the doctor was missed after the first fall. Nurses also honestly confessed that this level of care would have been nearly impossible, as “if you are 1:1 with a resident, no one else would get their care.”
When you have staff that is stretched too thin to provide necessary supervision and help to residents to avoid accidents, this raises fair questions as to whether this was an understaffed nursing home. Unfortunately, understaffing a nursing home is a basic feature 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.
