IDPH has cited and fined Willow Rose Rehab & Health after a resident experienced multiple falls, the last of which resulted in a right hip fracture.
Falls are a special area of focus in the care of nursing home residents, in part because the occurrence of a fall tends to beget more falls and because the injuries sustained in falls have such a negative impact on the health, well-being, and quality of life of nursing home residents. Nursing homes use a number of different tools to assess a resident’s fall risk, but three major factors in determining a resident’s fall risk are: (1) whether the resident has a history of falls, (2) any type of gait or musculoskeletal weakness of dysfunction, and (3) any type of cognitive impairment or lack of safety awareness which makes it less likely that a resident will understand or follow instructions for their own safety or make good decisions regarding their own safety.
When a resident is at risk for falls, a fall prevention care plan is required. A fall prevention care plan sets forth a series of steps that the staff will take on a day-to-day, shift-to-shift basis to prevent falls.
The resident in question experienced two back-to-back falls on consecutive days. The second of the nursing home falls was unwitnessed by any staff members. The resident was “observed on the floor sitting with her back against the bedside table. Incontinent of urine and shoes next to bed instead of on feet, lighting adequate, no apparent injuries noted at this time other than redness to left upper extremity (bicep) and to left side/back.”
The third fall, approximately a month later, was unwitnessed as well. According to an internal note, a nurse was called to assess the resident in her room. The resident was observed sitting on the floor, next to her bed. She was complaining of severe right hip pain, and her leg was noted to be “extremely rotated and shortened.” The nurse assisting the resident was unable to move the limb at all.
The resident was rushed to the emergency room via ambulance, where she was diagnosed with a right hip fracture.
There were a number of shortcomings in the care of this resident which contributed to the serious injury that she suffered in her third fall.
- The facility failed to properly investigate the root causes of these repeated falls per their own policy. After each fall, the facility conducted a “Quality Assurance Fall Analysis” that contained limited information and no detailed investigation of the root causes of each fall.
- The resident’s care plan was not updated with new interventions until almost a week after the third fall that resulted in the serious hip injury. There were no additional fall risk assessments done after the falls, only quarterly.
- After the third fall, some generalized fall interventions were added to the care plan like keeping the call light within reach, but did not include targeted interventions to address the specific circumstances around the resident’s falls.
- Staff interviews revealed a lack of understanding on when and how to update care plans and conduct fall investigations after incidents. When the investigator interviewed the DON (Director of Nursing), she noted that a relatively brief Quality Assurance Fall Analysis was conducted after each fall, and that “no other investigations occurred after falls.” The following day, the investigator conducted an additional interview with the DON, where she changed her message to more accurately reflect the facility’s Fall Prevention Policy. She claimed that she expected Fall Risk Assessments to be performed during admission, quarterly AND after a resident fall. She also mentioned that there should be fall interventions placed in the resident’s care plan after each fall, and that staff should be following the interventions.
One can only assume that the serious injury this resident suffered may have been prevented if those caring for the resident had properly investigated the root causes of the falls and updated the care plan in a timely manner with new interventions.
When a resident fails to get the care which is required, it raises a fair question as to whether this was an understaffed nursing home. Residents failing to get needed care is a hallmark of an understaffed and is also a hallmark 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.
