Pontiac Healthcare & Rehab Center in Pontiac, Illinois was fined by IDPH after a complaint investigation was undertaken after a resident suffered an intercranial bleed and multiple facial fractures after she had a nursing home fall while being toileted.

The resident at issue had long been assessed as being a fall risk, and the nursing home had put a fall prevention care plan into place. Nonetheless, she experienced two falls in which she fell forward from her wheelchair. Fortunately, she was not hurt seriously in either of those two falls. However, these falls demonstrated that she had a lack of trunk control which would allow her to maintain a safe, upright seated position. Therefore, part of her care plan included that she was to be reclined in her geri-chair when she was unattended.

On the day she was injured, the resident was placed on a bedside commode to go to the bathroom. The aide left to get an item and while she was unattended, the resident fell forward, hitting her head on the floor, suffering an intercranial bleed and multiple facial fractures.

During the IDPH investigation, the Administrator and care plan coordinator admitted that the aide should not have left the resident unattended on the toilet and that the aides had been trained that they should not leave resident who are at high risk for falls unattended when they are on the toilet.

There are a couple of take-aways from this incident:

1. The nursing home appropriately recognized that the resident’s lack of trunk control made her a fall risk and care planned for it appropriately by requiring the staff to recline her back in her geri-chair when she was unattended. However, the recognition of the safety risk was not applied throughout: that the resident was at risk for falling forward due to lack of trunk control, so she should also have not been left alone on the commode.
2. The nursing home administration admitted that the aide erred in leaving the resident unattended on the toilet and that they had been trained otherwise during in-services. As a matter of routine in our cases we obtain copies of records from any in-services which were conducted for the nursing home staff as that gives you a clear indication as to what they were actually told to do.

Other blog posts of nursing home falls:

Multiple fractures from fall at Accolade of Pontiac

Cumberland Rehab resident suffers brain bleed in fall from toilet

Unsupervised resident falls from wheelchair, breaks hip

Nursing home fall at Danville Manor results in fracture

Nursing home staff errors lead to fall and death at Burgin Manor

Fall from commode at Pekin Manor

Brain bleed from fall at Gibson Community Hospital Annex