IDPH has cited and fined Dimensions Living nursing home in Prospect Heights after a resident there was involved in two falls in four days – the first resulting in a broken jaw, the second resulting in facial fractures.

One of the basic truisms in the long-term care industry is that if a nursing home is unable to meet the care needs of a resident, the only proper course is for the nursing home to decline the admission of that resident.  In fact, federal regulations require that nursing homes have enough properly trained staff on had to meet the care needs of its residents on a 24/7 basis.

This resident was admitted to the nursing home from an assisted living facility.  The reason that the transfer was made was that the resident was having frequent falls in the assisted living facility, and one of the well-recognized truths about falls in a long-term care setting is the falls tend to beget more falls.  A history of recent falls is a factor that is accounted for in almost all fall risk assessment tools.

And this resident was in fact a fall risk – in addition to the history of falls, she also suffered from cognitive impairments with diminished safety awareness.  She also had generalized weakness and and required extensive assistance with transfers and mobility.  Her assessment concluded with a statement which stated that she required one-on-one care.

The first nursing home fall occurred approximately a month after the resident was admitted.  She was seated in a wheelchair doing an activity.  The activity aide assigned to run the activity was passing out to drinks to other residents when the resident fell forward from her wheelchair and hit the ground, suffering a fractured jaw.

The second fall occurred four days later.  The resident was again brought to the dining room for activities being conducted by an activity aide.  The resident again had another fall, this time hitting her head, resulting in significant bleeding and a lost tooth.  The resident was sent to the hospital due to complaints of pain and having a hard time breathing.  There a CT scan showed that she sustained facial fractures.

The resident’s assessment showed that she required a significant degree of supervision.  She was an obvious fall risk in light of her history of falls, cognitive impairments, poor safety awareness, and generalized weakness.  The assessment recited that she required one-on-one assistance, which is a level of care that nursing homes generally claim is impossible.  The facts here show not only did the nursing home fail to provide the care which they recognized in the assessment that she required, but they failed to provide the adequate supervision called for by federal regulations.  The activity aide was charged with not only conducting the activity, but also supervising the multiple residents who had been brought to the activity without the help of additional staff.  Inadequate supervision leads to fall, and did so here.

One of our basic 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.

Other blog posts of interest:

Grove of Skokie resident breaks leg due to violation of care plan

Grosse Pointe Manor resident falls and breaks hip after being left unattended

Addolorata Villa resident fractures hip in fall

Resident breaks both legs in unsafe transfer at Symphony of Buffalo Grove

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and and fined Fair Oaks Rehabilitation & Health Care Center in South Beloit after a resident there fell and suffered a broken hip due to the failure of a therapist to use a gait belt while walking with the resident.

Use of a gait belt is a fundamental fall prevention strategy.  A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers.  The gait belt allows the staff member assisting the resident help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall.  Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall.  Either places both staff and resident at risk for injury.

The resident at issue was considered at risk for falls and had been assessed as not being steady during transitions and walking and required the extensive assist of one staff member with walking in the corridor.  Extensive assist has a particular technical meaning – it means that the staff member is providing some physical assistance with the weight bearing.  Doing this properly requires the use of a gait belt.

On the day of this nursing home fall, the resident was being walked back from therapy by a COTA (certified occupational therapy aide).  There was no gait belt in use.  The aide later told the state surveyor, “[The resident] should have had a gait belt on for a security belt because she was unsteady.  I should have had a gait belt on her.  I don’t know why I didn’t use one.”  As they walked down the hall, a nurse sitting at the nurse’s station observed the resident and the aide, later telling the surveyor that it looked like the aide was not paying attention.  The resident began to tire and reached back to sit in a wheelchair, but instead fell to the ground, suffering a fractured left hip which required surgical repair.

Here, there was a failure in the fundamentals which led to this fall.  And it was not for a lack of equipment – the rehab director told the state surveyor that there was a drawer full of gait belts available in the therapy department.  Simple failures lead to very preventable accidents.

It is worth noting that the primary culprit in this incident was the therapy aide.  Frequently in nursing homes, therapy services are provided by an outside contractor.  However, the therapy aide was not the sole person bearing some responsibility for this fall as the nurse saw the aide walking with the resident and failed to act to correct the dangerous situation of walking the resident with no gait belt.

One of our basic 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.

Other blog posts of interest:

Fairhaven Christian Retirement Center resident dropped from lift, breaks hip

Resident left unattended in dining room at Ascension Saint Anne Place falls and fractures hip

Pleasant View Rehab resident fractures hip in fall

Bethany Rehab resident breaks arm in fall

Multiple falls leads to fall with broken hip at Tower Hill

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center nursing home in Chicago Heights after a resident there suffered a fractured leg after falling eight times in just over a year, with seven of the falls (including the last) being caused by her attempting to go to the bathroom unassisted.

One of the common situations where falls occur in nursing homes is when the resident attempts to go to the bathroom.  Nursing home residents are adults and when they are able to control their bowel and bladder and have sufficient cognitive wherewithal to recognize this, the desire to maintain their dignity takes over and they will attempt to make it to the bathroom unassisted, often leading to disastrous outcomes.

Before the fall at issue, this resident had 8 prior falls in just over a year’s time.  After each fall, the staff did the right thing and performed a root cause analysis in an effort to determine why the fall occurred.  When there is a root cause found, then there should be changes to the fall prevention care plan to take steps to prevent further falls.  The net result of the root cause analysis for 6 of the prior falls is that the root cause was the resident attempting to go to the bathroom unassisted.  Further to the nursing home’s credit, the care plan was upgraded five times to include getting a urinalysis, use of floor mats, a referral to physical therapy, rounding every 2 hours, and then finally rounding frequently and keeping resident in area where she could be supervised.

On the day of this nursing home fall, the resident was attempting to go to the bathroom unassisted and fell again.  This time, she suffered a fracture of the femur which resulted in her being wheelchair bound.

The nursing home did many things right in the care of this resident.  She was clearly a fall risk and was treated as such.  When she sustained falls, there was an effort made to determine the cause of those falls and to try to prevent further falls.  However, there was a common theme among almost all the falls in that she was attempting to go to the bathroom unassisted.  One means of addressing the behavior would be to put the resident on a toileting schedule.  This would involve the staff tracking the resident’s bathroom habits over  period of several days so that the patterns could be discovered, and once those are identified, the staff would be scheduled to bring the resident to the bathroom when the need was expected.  This was never tried for this resident, leading to repeat falls with changes in the care plan of dubious value.

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.

Other blog posts of interest:

Symphony at Palos Park suffers brain bleed in fall from toilet

Prairie Manor resident suffers brain bleed after being rolled out of bed

Mechanical lift accident at South Holland Manor

Promedica Skilled Homewood resident fractures hip in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Symphony of Palos Park nursing home after a resident there suffered a brain bleed as a result of a fall which occurred due to him being left unattended while seated on a toilet.

Federal regulations pertaining to nursing home falls call for residents to receive supervision and assistance as needed to prevent accidents.  Falls are a form of accident, and the regulations require nursing homes to take the required measures to prevent this kind of accidental injury.  How does the staff know what has to be done to prevent falls?  The basic answer to that is the care planning process.

During the care planning process, there is an assessment done of the risks to the health and well-being of the resident.  This results in a care plan being developed which sets forth a specific set of measure which staff members are assigned to carry out on a day-to-day, shift-to-shift basis.  The care plan must be communicated to the staff charged with carrying it out and then it must actually be implemented.  Finally, its effectiveness must be evaluated on an ongoing basis and then revised if there are changes in the resident’s needs or it proves to be ineffective in practice.

The resident at issue had a number of medical conditions which placed him at risk for falls, including a history of epilepsy, cognitive impairments, and generalized weakness.  The resident was assessed on multiple occasions using the facility’s fall risk assessment tool which scored him consistently as 18 or higher.  On the fall risk assessment tool used at this nursing home, any score 10 or higher indicated a high risk of falls and required that the resident be placed in the “red leaf” fall prevention program.  Staff were trained that residents who were in the red leaf program were not to be left unattended on toilets.

On the day of this nursing home fall, the resident was brought to the toilet by an aide.  The aide who brought the resident to the toilet then left to get a beverage for the resident, telling him to pull the call light when he was finished.  When the aide returned to the room, she found the aide on the floor.  The resident was sent to the hospital where he was diagnosed as suffering from a brain bleed.

There was clearly a break down in the care that this resident received.  He was assessed as a fall risk and the nursing home had a reasonable procedure in place to address that fall risk: that residents should not be left unattended while seated on a toilet.  One reason for this is that it actually requires a significant amount of trunk control to maintain position on the toilet.  Unfortunately, either the risk level for this resident was not communicated to the aide involved, or she was not properly trained on the red leaf fall prevention program.  In either event, this breakdown in the care led to this resident’s fall and injury.

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.

Other blog posts of interest:

Promedica Skilled Homewood resident fractures hip in fall

Westmont Manor resident suffers brain bleed after being rolled from bed

AHVA Care of Stickney resident breaks hip in fall

Failure to supervise Westmont Manor resident leads to fall and broken hip

Resident at Chateau nursing home in Willowbrook suffers spinal fractures in wheelchair accident

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Generations at Elmwood Park nursing home after a resident there suffered a broken hip in a fall.

Nursing homes are required to complete a series of documents called the Minimum Data Set (MDS).  The MDS is submitted under penalties of perjury to the federal government and is a statement as to the condition of the resident and the levels of care and assistance that the resident requires.  The reason that the MDS is submitted to the federal government under penalties of perjury is that the MDS forms part of the basis by which the nursing home is paid and this is the certification by the nursing home that a) this is the kind of care that the resident requires and b) that the nursing home is in fact requiring it.

The resident at issue was 101 years old and was wheelchair bound, but was largely independent.  However, her MDS certified that she required assistance of one staff member with getting her pants on.  This was confirmed by the nursing home’s occupational therapist who confirmed that she needed at least supervision with getting her clothes on her lower body.  However, most staff members charged with her care believed that she was independent in all aspects of daily living, including dressing herself.

On the morning of this nursing home fall, the resident was seated in her wheelchair in her room getting ready for the day.  Staff present in her room knew that she was getting dressed but no one waited to provide supervision and assistance with her getting her pants on.  She attempted to do so herself but lost her balance while standing to pull her pants up and fell.  She landed to one side and was assisted back to bed by staff.  However, the fact that a fall occurred was not communicated to the resident’s doctor so it was not until the following day that she was sent to the hospital after staff heard her telling her family about the fall and that she was having pain in the side.  There, the fractured hip was diagnosed and treated.

Nursing homes are businesses, and well-run businesses have processes that must be followed to ensure that necessary services are provided as a matter of routine.  This should include incorporating care called for in the MDS into the resident care plan, having the contents communicated to the staff charged with carrying it out, and then having that care actually delivered.  Here there were multiple breakdowns in the delivery of care.  The care called for in the MDS was no incorporated into the care plan, communicated to the staff, or actually delivered.  The assessments clearly called for supervision and assistance with putting on pants but that was not done.  As a result, this resident fell and suffered a fractured hip.

Past that, a fall is something that requires physician notification.  This was not done until the following day leaving the resident with no care of relief from pain from the fractured hip.  When asked, most nurses working in a nursing home setting will agree that subjecting a resident to unnecessary pain is a form of nursing home abuse.

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.

Other blog posts of interest:

Bella Terra Elmhurst resident fractures hip, dislocates knee is fall

Inverness Rehab resident suffers multiple fractures in fall

Tower Hill resident suffers fractured hip in fall

Assisi at Clare Oaks resident breaks neck in fall from wheelchair

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there suffered a broken leg in a fall while getting up from the toilet.

Falls are a major source of concern in the long-term care industry.  Falls are associated with increased mortality rates, steep declines in the quality of life when there is significant injury, and increased risk of falls in the future.  For these reasons, and because of the requirements of federal regulations, fall risk is a specific area of focus in the care planning process.

When fall risk assessments are done, the nursing home will use its assessment tool to evaluate the resident’s fall risk.  Two factors that are in in all well-done fall risk assessment tools are (1) some form of gat/balance/musculoskeletal dysfunction and (2) some form of cognitive impairment such as intermittent or constant confusion, dementia, poor safety awareness or judgment, and/or impulsivity.  These combine to make the resident a fall risk because the physical issues leave the resident at risk for falls or loss of balance and the cognitive deficits increase the chances that the resident will not follow instructions, ask for assistance, or make good decisions for their own safety.

This resident had many of the factors that made her a fall risk.  Her Minimum Data Set (MDS) indicated that the resident had moderate cognitive impairments, that she required extensive assist of staff with transfers, toileting, and personal hygiene, and that she was unsteady when rising from a seated to standing position and was only able to stabilize with staff assistance.  The resident had a known history of attempting to rise from the toilet unassisted – something which could result ion a fall.

At the time of this nursing home fall, the facility had in place a policy which stated residents who are i9dentified as being at risk for falls if left unattended on the toilet should not be left unattended while on the toilet.

On the day that the fall occurred, the resident was brought to the toilet by an aide who then left the resident to go get hair rollers.  While she was doing that the resident attempted to rise from the toilet unassisted and fell.  She was brought to the hospital where a broken femur was diagnosed.

This is a resident who was at risk for just this kind of fall based on the documented findings of cognitive impairments and difficulty with standing from a seated position – all documented on her MDS,  as well her known history of attempting to get up unassisted from the toilet.  Based upon prevailing standards pf practice as well as the facility’s own policy, this resident should not have been left unattended.  The administration of the nursing home agreed with this, writing the aide up.

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.

Other blog posts of interest:

Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt

Westminster Village resident suffers multiple fractures in fall

Resident breaks hip in fall at McLean County Nursing Home

Christian Nursing Home resident suffers severe leg injury in fall

Arcadia Care Bloomington resident breaks hip and back in from from wheelchair

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Park Pointe Healthcare and Rehab nursing home in Morris after a resident there suffered multiple fractures due to falling down a stairwell.

The resident involved in this fall down the stairwell had a care plan for wandering. Wandering is also known as elopement in the long-term care industry and is a serious risk of harm to the resident. Residents who wander can find themselves in situations where they are faced with hazards which due to physical or cognitive limitations, they are unable to safely face or address. This resident was also a fall risk because she was wheelchair-bound and had musculoskeletal deficits as well as significant cognitive deficits.

For residents which are at risk of harm due to wandering/elopement or falls, there are a number of steps that can be taken to mitigate that risk.  One of the principal steps is to keep the resident under close supervision.  Doing this reduces the risk from injury for both falls and wandering, and is consistent with the requirements of federal regulations.

On the day of this nursing home fall, the staff noticed that a plastic curtain, which went to an otherwise-empty COVID unit, had been disturbed. The staff checked the rooms in the COVID unit for  residents but did not find any. They returned to their own unit and discovered that the resident involved in this incident was missing.

They looked throughout the facility but were unable to locate her and returned to the COVID unit.  Upon return to the COVID unit, they re-inspected all of the rooms and were unable to find the missing resident. Coming to the end of the hallway, they noticed that the door to the stairwell was closed, but the green light for alarm was flashing. This was an indication that the alarm was not armed.

The staff opened the door and found the resident down at the bottom of the stairwell, with her wheelchair two or three steps down the stairwell. She apparently had begun to fall down the stairs. The wheelchair stopped, and she was ejected from the wheelchair. An ambulance was called. The resident was brought to the hospital where she was diagnosed as having a fracture to her clavicle, as well as broken ribs.

There were two major shortcomings in the care that this resident received. First, any resident who is at risk for falls and is also known as a wanderer and at risk for elopement should be a resident who is closely supervised. The citation issued by IDPH indicates that the staff was well aware of her history of wandering and that she wandered actively throughout the facility, often looking for her husband, who is in fact, not a resident at the facility.  Keeping her under close observation would have likely prevented this injury, especially given the amount of time that it would have taken her to travel that distance and open not only the door to the stairwell, but also the curtain to the COVID unit.

The other major shortcoming in the care that this resident received is that the stairwell was not secured with either a lock or an alarm. Stairwells pose a special risk of harm to nursing home residents.  This is partially due to the fact that many are simply not able to negotiate them safely as well as the fact that stairwells are an area where they are out of view of the staff.  Once a fall occurs in a stairwell, it is likely that the resident will endure a prolonged period of time before the fall is discovered and care for any injuries from the fall can be offered.

In this particular case, the practice at the nursing home was that the maintenance staff would check the alarms throughout the facility during weekdays, but there was no one specifically assigned to check the alarms on weekends – which is when this fall occurred. As a result, the stairwell was not secured with locks or alarm leading to the fall and injuries sustained by this resident.

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.

Other blog posts of interest:

Warren Park Health & Living Center resident suffers brain bleed in fall down stairwell

Accolade of Pontiac resident fractures hip in fall after call light left out of reach

Resident breaks both legs in fall from bed at Grove of Fox Valley

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Piatt County Nursing Home after a resident there fractured a hip in a fall due to the failure of an aide to provide needed supervision and assistance.

Falls are a major issue in the long-term care industry due to the serious negative effects that they have on the mortality and quality of life of nursing home residents.  Therefore, fall prevention is always a specific area of focus in the care planning process.

The care planning process begins with an assessment of the resident’s fall risk.  Nursing homes use a variety of tools to assess fall risk, but one common feature in almost all tools is that (1) some form of musculoskeletal weakness, balance issue, or gait dysfunction and (2) some form of dementia, forgetfulness, intermittent or constant confusion, poor safety awareness or judgment, or some other form of cognitive impairment are major factors in weighing the resident’s fall risk.  The reason that cognitive impairment contributes to fall risk is that the resident cannot be counted on to follow instructions or make good decisions for their own safety.  Where cognitive impairments are a contributing factor to fall risk, close supervision is a mainstay of fall prevention – consistent with the requirements of federal regulations.

The resident at issue was properly assessed as being a fall risk.  Among the factors that made the resident a fall risk were having mobility impairments, poor balance, an unsteady gait, a history of falls, and according to the resident’s Minimum Data Set (MDS) he required extensive assist of the staff with transfers and to stabilize.  On the cognitive side, he was noted to have long and short term memory problems.  He further had a known history of attempting to self-transfer and forgetting to use the call light.  He was considered a fall risk because of his impaired gait and forgetting and/or overestimating his limits.

On the day of this nursing home fall, the resident activated the call light for assistance to use the commode.  The aide arrived to assist the resident.  He provided the resident his walker and then turned and went to close the privacy curtain for the resident.  As the aide was closing the privacy curtain, the resident attempted to stand using the walker.  As he did so, he lost his balance and fell to the floor.  The resident’s leg was rotated outward with a leg length discrepancy – obvious signs of a fractured hip.

The resident was brought to the hospital where the fractured hip was confirmed.  The resident was transferred to a larger hospital where he underwent surgery to repair the fractured hip.

The facts of this fall show how quickly small failures in the care that the resident is provided can have catastrophic consequences.  The aide responded to the call light (something that does not always happen) and attempted to provide the resident with a measure of dignity by closing the privacy curtain.  However, he did so after providing the resident with the walker.  He was not in a position to provide the resident with the needed assistance with transferring and stabilizing when he rose from the position seated at the edge of the bed.  Further, he had his back turned to a resident whose known history and behaviors spoke to a need for close supervision.  The Director of Nursing admitted as much, telling the state surveyor that simply closing the privacy curtain when he entered the area could have prevented this fall.

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.

Other blog posts of interest:

Piatt County Nursing Home resident breaks neck in fall from power recliner

Westminster Village resident suffers multiple fractures in fall

Moweaqua Rehab resident fractures hip in fall

Mason City Area Nursing Home resident suffers fractured hip in fall due to failure to use gait belt

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Accolade Healthcare of Pontiac nursing home after a resident there suffered a hip fracture in a fall.

Fall prevention is a major focus of care in nursing homes because falls have such a devastating effect on the mortality and overall quality of life for nursing home residents.  One mainstay of fall prevention is encouraging the use of a call light and leaving personal items such as books, glasses, phones, and so forth in easy reach of the resident.   The basic idea of having things in easy reach is that residents don’t have to get up and down from a seated position and walk across the room to get anything.

Another mainstay in fall prevention is use of a call light.  Call lights can be effective in summoning the staff for assistance.  However, for that to happen, the call light must also be left in easy reach of the resident – just as with personal items.

The resident at issue was a very clear fall risk.  She suffered from moderate cognitive impairments (and thus could not be relied upon to consistently make good judgments for her own safety) and had difficulty walking, using a walker or a wheelchair for mobility.

On the day of this nursing home fall, the resident was found on the floor.  Her left leg was rotated, a common sign of a hip fracture.  The resident did not have on nonskid footwear and had not activated her call light.  However, the nurse on duty noted that the call light was hanging on the call light box on the wall.  The resident was brought to the hospital where she was diagnosed as suffering from a hip fracture.

This fall was due to the failure to take the simple step of leaving the call light in a place where the resident could easily reach it without getting up.  However, the call light had been placed on top of the call light box, out of reach.  Besides being a common-sense failure in care, it was also a violation of the facility’s own policies and procedures which called for the call light to be in easy reach of the resident.

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.

Other blog posts of interest:

University Rehab resident falls from bed during incontinence care and breaks hip

Westminster Village resident suffers multiple fractures in fall

Resident breaks hip in fall at McLean County Nursing Home

Piatt County nursing home resident breaks neck in fall from power recliner

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Barry Community Care Center nursing home after a resident who was a known fall risk was left unattended at the nurse’s station and fell, refracturing a recently broken hip.

Falls are a major issue in the long-term care industry because they have such significant implications for the well-being of residents.  Fall risk is one of the areas which is specifically assessed during resident assessments during the care planning process.  There are a number of tools that are used at different facilities, but the two common threads to assessing a resident’s fall risk are (1) some type of gait, neurologic, or musculoskeletal dysfunction which makes it difficult for a resident to walk, stand, or transfer safely, and (2) some type of cognitive deficit such as dementia, intermittent or constant confusion, or simple poor safety awareness or judgment.

The reason that cognitive deficits contribute to a resident’s fall risk is that the resident cannot be counted on to follow instructions or take basic precautions for their own safety.  Because of this, keeping the resident under close observation is a mainstay of fall prevention.  In fact, federal regulations pertaining to nursing home falls require nursing homes to provide supervision and assistance necessary to prevent accidents.  Usually, this takes the form of keeping residents who are at risk for falls near the nurse’s station, the dining room, the activity area or some other common area where the staff can keep an eye on what the residents are doing.

The resident at issue here was admitted to the nursing home after suffering a fractured hip which was surgically repaired.   The resident was assessed as being at risk for falls.  The assessment included findings that the resident was oriented to person only – indicating significant cognitive deficits.  Before the fall at issue, the resident had two prior falls, and the occurrence of a fall is a predictor of additional falls in the future.

On the day of this nursing home fall, the resident was brought to the nurse’s station so that the staff could keep her under direct observation.  However, she apparently decided to stand on her own and fell, pulling the wheelchair down on top of her. It was recorded as being an unwitnessed fall, indicating that even though the resident was brought to the nurse’s station to be kept under observation, she was left unattended and the fall resulted.

The resident was brought to the hospital where scans showed a fracture around the prosthesis from the original hip fracture.  The citation did not recite what was done to repair the fracture, but any surgical repair would necessarily be a difficult and complex operation and would result in loss of whatever recovery had been made from the original fracture.  Without surgery, the chances of the resident being able to regain any significant measure of ability to bear weight would be minimal which in turn has serious negative long-term consequences for the overall health and well-being of the resident.

Whenever there is a report that staff which were required were not present, this raises a question of whether the nursing home is understaffed.  Sadly, understaffing of nursing homes is a feature, not a bug 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.

Other blog posts of interest:

Failure to use gait belt leads to fall at Clayberg Nursing Center in Cuba

Farmington Country Manor resident breaks leg sue to failure to follow care plan

Pittsfield Manor resident suffers fatal fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Mar Ka Nursing Home in Mascoutah after a resident there broke both legs in a fall while being readied for a shower.

One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS.  The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed.  The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath.  Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.

So, when the MDS states that a resident requires the assistance of two staff with transfers, that is telling the federal government that this resident requires the help of two staff members moving bed to wheelchair, wheelchair to chair, and so forth.  When a resident requires extensive assist, that means that the staff must physically hold and support the resident during the transfer movement.

To do this safely, use of a gait belt is required.  A gait belt is a sturdy canvas strap that is applied to the midsection of the resident.  It provides the staff with a firm place to get a hold of a resident without trying to grab on to the resident’s body (many residents suffer from osteoporosis or brittle bone disease, which leaves the them susceptible to fractures from being grasped that way) or their clothing which is not designed for that kind of use and susceptible to tearing.

On the day of this nursing home fall, the resident was brought to the shower by a single aide.  The aide was in the process of transferring the resident from her wheelchair to a shower chair and was undressing her.  The aide was not using a gait belt.  While she was doing this resident’s leg slipped on the wet floor.  The aide could not control the resident and was lowered to the floor.  There was an obvious deformity to one leg.

The resident was brought to the hospital where x-rays showed that there were fractures to the femur in both legs, with a fracture just above the resident’s prosthetic knee on the left side.  The resident had to undergo surgery to repair both fractures.  These injuries will have serious long term implications for the health and well-being of the resident, including by placing her at increased risk for developing bed sores or suffering pneumonia.  Additionally it is unlikely that she will regain even her prior limited level of function after this injury.

There were a number of shortcoming in the care that this resident received which led to serious injuries with significant long term consequences for this resident.  The resident was being transferred at the time of her injury by a single aide when two were required.  Capping it off, that aide was not using a gait which was necessary to make the transfer safely.  Finally, federal regulations require that the resident environment remain as free of accident hazards as possible.  The loss of balance here was brought on by the slippery floor of the shower – a condition which could have been easily alleviated by the use of anti-skid strips on the floor of the shower.

When you have one person dong a two-person job it raises questions of understaffing of the nursing home.  Unfortunately, failing to provide adequate staffing levels is a planned 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.

Other blog posts of interest:

Sling breaks during transfer at University Nursing & Rehab

Red Bud Regional Care staff fails to respond to call light, leading to fall

Broken ankle from fall at Aperion of Mascoutah

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Loft Rehab of Rock Springs nursing home in Decatur after a resident there suffered a fractured hip due to tripping over decorative landscaping in the facility smoking area.

Some are surprised to learn that residents in nursing homes are permitted to smoke – it is a health care facility after all!  However, nursing homes are the home for the residents there and as adults, residents have the right to smoke.  However, unlike in a private residence, residents in a nursing home are not permitted to smoke wherever they please.  Nursing homes have a designated area – usually a patio – where residents are permitted to smoke.

However, like all areas within a nursing home, the smoking area must be safe for residents.  Federal regulations relating to nursing home falls require that the facility be as free of accident hazards as possible.  Further, one of the standard fall prevention measures in every fall prevention care plan is to keep areas free of clutter and tripping or slipping hazards.

The resident at issue was someone who was at risk for falls.  He required the assistance of a wheelchair or walker for mobility and had difficulty when rising from a seated position.

On the day of this nursing home fall, the resident went to the smoking area accompanied by a member of the housekeeping staff.  As he got up from his chair to return indoors, the wheel to his walker got caught on a decorative railroad tie.  The resident fell to the ground with obvious pain to the left hip.  He was brought to the emergency room where he was diagnosed with a hip fracture.

The post-fall investigation concluded that the decorative railroad tie was the cause of the fall and an unnecessary tripping hazard.

This fall demonstrates how the tension between the business objectives of nursing home management clashes with the care needs of residents.  Management wants to have an attractive facility – families that tour the facility want to see their loved ones in a place that at least looks nice.  Things like decorative railroad ties on a patio are stylish and visually appealing even as they create additional hazards for residents.  Having the decorative railroad tie there was a choice that management made which sacrificed the safety of residents.  Unfortunately that is a common thread in the decisions that get made about how nursing home are managed.

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.

Other blog posts of interest:

Aperion Care St. Elmo resident breaks hip in fall

Fall with broken hip at Heritage Health in Mt. Zion

Resident at Hickory Christian Village in Forsyth suffers multiple fractures in fall

Auburn Rehab resident suffers hip fracture in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.