IDPH has cited and fined Heritage Heath nursing home in Springfield after a resident there sustained repeated falls, the last of which ended with her suffering a broken arm and a brain bleed.
One of the things that motivates a family to admit a loved one to a nursing home is the occurrence of falls at home, to the point that the family has accepted the reality that they cannot keep them safe at home. When this happens, they are looking to the nursing home to provide a level of safety and supervision that could not be managed at home.
That was the case here, as one of the things leading this family to admit their mother to a nursing home was the fact that their mother had an unsteady gait and was often confused and would forget to ask for help before getting up on her own. Further, she was obsessed with neatness and would often be up straightening and adjusting things. Before her admission to the nursing home, she had one fall which resulted in a broken humerus.
This is a resident who was clearly at risk for a nursing home fall when she came in the door. She had suffered from confusion, had an unsteady gait, and a history of prior falls. She was assessed early on as being at risk for falls, and a fall prevention care plan was put into place.
Nonetheless before her final final fall, she sustained a total of 24 (!!!) falls. When residents experience falls, especially repeated falls, review and revision of the care plan is in order. Falls tend to beget additional falls which means that progressively more aggressive measures are in order.
The second to last fall that this resident experienced was less than a week before the final one. After that fall, her care plan was reviewed, but no changes were made to her care plan. The final fall was an unwitnessed fall. As a result of the fall, she suffered a broken humerus and a brain bleed.
This resident was one who was clearly at high risk for falls. She had a history of falls and had demonstrated and inability to control her behavior to mitigate the risk of falling. To that end, keep her under constant direct observation was called for. A request for a psychiatric consult was also likely in order. Given that the resident experienced an unwitnessed fall, the step of keeping her under constant direct observation was either not incorporated into her care plan or was not being implemented.
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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