An 82-year-old resident of the Symphony of Joliet nursing home in Joliet, Illinois broke his neck after rolling out of his bed. The resident has seizures and dementia. He cannot speak or walk, and depends on staff for virtually everything including being repositioned in bed.
In late December, he was found on the floor of his room by a Certified Nurses Aide (CNA). There were lacerations to the man’s head, and he lost a tooth in the fall, so clearly he was unable to break his fall in any way. Paramedics noted that there was no safety mattress next to the bed and the bed alarm had not sounded when the man fell.
The subsequent investigation revealed that the CNA who positioned him immediately prior to the fall did not put any assistive devices in place that might have helped to prevent the accident including the extra mattress that was supposed to be left on the floor at night.
The plan of care for the resident listed a series of interventions that should have been in place that night. First, an alarm to prevent falls was to be placed on the bed. The bed was to be set to the lowest position, just a foot or two off of the ground, the resident was to be placed in the center of the bed, and an extra mattress was to be left on the ground at night next to the bed.
Nursing home falls are extremely frustrating for families, especially when they are caused by nursing home neglect. In this case, not only should the resident have had a better protection from the fall, but any fall that did occur should have been far less brutal and damaging.
Two of the interventions, setting the bed to the lowest setting and placing a mattress next to the bed, would only take seconds to put in place. Instead, the resident suffered a broken back and lost tooth. The injuries didn’t need to happen.