IDPH has cited and fined South Suburban Rehab nursing home in Homewood after a resident there sustained multiple injuries in a fall.
One thing commonly seen is a push to get hospital patients out the door over the weekend. There are a host of reasons that hospitals prefer to get discharges done before the close of business Friday, Saturday at worst. The problem that comes up from the perspective of the new nursing home resident is that the transition doesn’t always go so smoothly. And that was the case for this resident.
The resident at issue was admitted to the nursing home from the hospital at 6:30 p.m. on a Saturday evening. The report from the hospital was that he was a fall risk, and his family also described him as a fall risk with a history of falls at home. The staff promised that a floor mat would be put down.
Fall prevention care planning is a discipline which helps assure that the care the resident needs to stay safe and healthy is delivered on a day-to-day, shift-to-shift basis. One of the things that makes care planning work is that the care plan is reduced to writing. Having a written care plan means that everyone knows (or should know what needs to be done). Not having it in writing reduces the crucial to-do’s that must be done to keep a resident safe to handful of things said from one staff member to another during change of shift. It is a formula for dropping the ball, and that is what happened here.
When the nurse came on duty for the morning shift, she saw that the resident’s legs were very stiff. She helped him to a wheelchair, put a floor mat down, and brought him to the dining room where he remained for the rest of the shift. When the CNA came in for the afternoon shift, she helped the resident to bed. Unaware that he was a fall risk, she moved the floor mat away, thinking that it was for use by his roommate. Shortly thereafter, the resident fell from bed, sustaining a cut to the forehead, a broken nose, and a separated shoulder.
He was brought to the hospital, but had ongoing complaints of intractable pain and was eventually placed on morphine and discharged home on hospice.
When the state surveyor arrived, it was clear that the staff did not know who should be preparing a care card to tell the aides what needed to be done when the restorative nurse (the one who normally did it, but was there only Monday through Friday) was not available. As a result, no care card was prepared, and the care that this man received was random chance nursing. This is a formula for disaster that ended badly yet predictably – with an utterly preventable nursing home 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.
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