IDPH has cited and fined Stephenson Nursing Center in Freeport after a resident suffered a broken hip due to being pushed down by a fellow resident.
The assailant was well-known to staff and fellow residents as being physically aggressive who did not enjoy interacting with fellow residents and did not allow other residents to touch her. There were multiple documented events of her being aggressive toward other residents and staff members, including another incident where she pushed another resident to the floor. The staff was aware of her aggressive behaviors and knew that she had to be watched closely, but the Director of Nursing was apparently unaware of the incident where she pushed another resident to the floor until IDPH came in to investigate this incident. The facility social services assistant told the state inspector that when residents have aggressive behaviors, they are supposed to be put on 1:1 supervision, but there was no evidence that this was done.
The victim suffered from dementia and musculoskeletal weakness. She had a known set of behaviors that included wandering through the facility in way that disrupts care and intrudes on the privacy of others. She had been assessed as a fall risk, and there was a fall prevention care plan in place which called for the use of a gait belt and assist of one with walking.
On the day of the incident, the victim was walking down the hall unassisted. She reached out to the assailant to touch her on the shoulder. When she did so, the assailant turned around and pushed her down. The victim fell to the floor, in obvious pain with her leg rotated. She was taken to the hospital where she was diagnosed with a broken hip. During the hospital admission to treat the broken hip, she developed pneumonia which is a common consequence of a hip fracture.
This is a regrettably common scenario in nursing home resident-on-resident assault cases. You have a resident who is known to wander and intrude on other’s private space and another resident who is known to be physically aggressive. It is a combustible mix that has predictably sad results.
On one level, this nursing home assault was very simple to prevent. The victim was supposed to be 1:1 assist with walking and a gait belt in use, which meant that she should not have been up walking around by herself which was what happened. Had she been accompanied by an aide, she could have been steered away from the assailant or at least had her fall broken by the use of the gait belt.
Past that, there needed to be a more focused approach to the assailant’s known aggressive behavior. The facility did not have policies which addressed resident-on-resident aggression, and there was no care planning in place which specifically addressed this resident’s aggressive behavior. The staff was all well aware of the behavior and that she was someone who needed to have “an eye kept on her” but there was no specific care planning done as to how that would be implemented on a day-to-day, shift-to-shift basis or what specific steps should be taken to lessen the aggressive outburst. It was simply catch-as-catch-can, which is a horrible way to address known issues of resident safety.
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