IDPH cited and fined Heritage Health nursing home in Mendota after a resident there experienced two falls in two days, the second resulting in a fractured lumbar vertebra.
The resident at issue had been admitted to the nursing home for rehabilitation following a knee replacement surgery. She was assessed as having cognitive issues which increased her fall risk including confusion, memory problems after 5 minutes, and overestimating or forgetting her limits. This combination of factors made her a high fall risk – there are orthopaedic issues which create a risk of falls and cognitive issues which can lead to behaviors that increase fall risk, specifically getting up without assistance or supervision. The fall prevention care plan only called for assist of two using a gait belt and walker for walking and assist of two with transfers.
The first fall actually occurred on the day of her admission. She thought that she heard her daughter’s voice in the hallway and got up from her recliner using her walker and walked out into the hallway where she lost her balance and fell, bumping her head.
One of the truisms regarding nursing home falls is that a first fall tends to beget additional falls. When a resident experiences a fall, that is a situation which requires physician notification and revision of the care plan. The occurrence of a single fall is a strong indicator that the current care plan is inadequate for addressing fall risk and needs to be revised.
The second fall occurred the following day. The resident was again in her recliner in her room when she got up and walker without her walker to the doorway of her room without her walker when she lost her balance and fell landing on her back. She complained of significant lower back pain and was sent to the emergency room where x-rays showed a fracture of the L4 vertebra.
When a resident suffers from cognitive issues such as dementia, intermittent or constant confusion, or poor safety judgment, this is a significant factor in a resident’s fall risk profile. It means that they cannot be counted on to do the things that would help assure their own safety like calling for and waiting for help. Federal regulations relating to nursing home falls require that residents receive supervision and assistive devices necessary to prevent accidents.
In the past this kind of resident would have been provided with a bed alarm which would have served to alert the staff and remind the resident to wait for help. However, even with federal regulations discouraging (but not prohibiting) the use of bed alarms, the nursing home still has an obligation to provide supervision necessary to prevent accidents.
The cognitive difficulties that this resident was plainly experiencing (and which tend to be at their worst when first admitted to a nursing home) needed to be specifically addressed in the resident care plan, but was not. Most often, the care plan would include keeping the resident in a common area or at the nurse’s station so that they can be supervised by staff. The failure to include specific interventions in the care plan to address the cognitive issues, especially in light of the fall on the day of admission, was a significant failure on the part of the nursing home.
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