A nursing home fall resulting in a head injury with staples resulted in a citation by IDPH to Holy Family Villa nursing home in Palos Park.
The incident at issue is an interesting one because it relates to the use of a toileting schedule as a fall prevention tool and the communication aspect of care planning for nursing home residents.
Incontinence is a contributing factor to two specific types of cases we see in our practice on a regular basis: bed sores and falls.
In terms of bed sores, when a resident is incontinent of bowel or bladder, exposure to urine and feces help keep the skin moist. Further, the chemicals in urine and feces helps break down the skin which leads to the development of bed sores and increases the risk of the development of infections such as cellulitis or osteomyelitis. It is one of the really well-recognized risk factors for the development of bed sores and is incorporated into the Braden scale.
Incontinence also is a well-recognized risk factor for nursing home falls. This comes principally from residents attempting to reach the bathroom without assistance simply in an effort to avoid soiling themselves. Whether a resident suffers from incontinence is a factor in every well-recognized form of fall risk assessment used in the long-term care industry.
One way that incontinence is addressed in the long-term care industry is by getting residents on a toileting schedule. How this is done is that over several days, the staff records when it is that the resident had to go to the bathroom and what is was. This is called a bowel and bladder assessment. Using that data, the staff can plan to get the resident to the bathroom at certain times of the day.
When this is done right, it serve to greatly reduce the risk of developing bed sores and falls. When a resident does not soil themselves, urine and feces do not make the skin moist and break down the skin causing bed sores. When a resident is being brought to the bathroom when they need to go, they are not trying to do it themselves and falling and breaking a hip.
In this case, the staff did the bowel and bladder assessment and found that there was a regular pattern to the resident’s incontinence. The facility policy called for bringing the resident to the toilet 10-15 minutes in advance of the anticipated times.
On the night that this resident fell, there was an aide on duty who was not familiar with the resident and was not aware of the any special plans for toileting the resident. It was not part of the usual practice there for CNA’s to do shift-to-shift reports. The resident’s pattern was to go to the bathroom at midnight. The aide on duty that night checked on the resident at 11 pm and saw her asleep and planned to return at 1 am.
At 12:40 a.m., the resident was heard calling for help. Responding staff members entered the room and saw the resident on the floor with blood coming from her head. She was brought to the emergency room where she received 10 staples and two units of blood. After she received the two units of blood she became unresponsive and died within 48 hours of the fall. This may well be a basis for a wrongful death suit.
There was a reasonable plan of attack in place at this nursing home: they did a bowel and bladder assessment and came up with a data-based toileting schedule. The problem is that no one ever bothered to tell the person charged with carrying it out what had to be done and as a result, there was a fall which may have well cost this woman her life.
Past that, this event is an indicator of a systems failure at this nursing home in that there was clearly no mechanism to inform that direct care staff what they should be doing.
These kinds of unnecessary injuries and deaths of nursing home residents are the basis of our practice. If you have a loved one who suffered injuries due to a very preventable accident such as this, please contact our experienced Chicago nursing home lawyers to determine what your rights are and what steps you can take to prevent this kind of accident from happening to another family.
Other blog posts of interest:
Hygiene and bed sore issues at Holy Family Villa
No fall prevention care planning at South Suburban Rehab
Failure to use mechanical lift results in ankle fracture
Resident rolled from bed at Harmony Rehab
Two serious falls at Holy Family Villa
Multiple injuries in fall at Symphony of Midway
Click here to file a complaint against a nursing home with the Illinois Department of Public Health
