If you took a poll of 100 nursing home staff members and asked them how important it was to follow the plan of care, 100 out of 100 would say that it is very important. And yet time and again, staff members make a conscious decision to break those plans. Sometimes, the plans are broken because of short-staffing. Other times, staff members are not properly informed about updates to the plans.
Unfortunately, there are other times when staff seems to determine that they know better than the doctors and nurses who developed the resident’s plan of care. When that happens, residents suffer.
A resident of the Asta Care Center of Colfax in Colfax, Illinois experienced a nursing home fall that resulted in a fractured hip after staff members failed to follow the plan of care for an 89-year-old resident.
The resident was admitted to the nursing home on March 28th of this year. He was evaluated for risk of nursing home falls and scored an 18. Anything over ten is considered a high risk of nursing home falls.
He had a history of falling in his home. The last fall had resulted in a broken bone. He was alert, but confused at times, and had a tendency to try to transfer himself in the bathroom and to his bed.
Less than three weeks after being admitted to the facility, the resident fell. He was sitting in a chair near the nurses’ station, but was out of direct sight when he managed to get to his feet, but he didn’t make it far. He was found on the floor yelling in pain.
A chair alarm was supposed to always be activated when he was in a chair. A chair alarm sounds when pressure is removed from it. Asta Care Center staff felt that the pressure alarm wasn’t necessary, and didn’t use it.