IDPH has cited and fined Bria of Chicago Heights nursing home after a resident suffered her third fall in eight days, the last one causing a brain bleed.
The first of these occurred on July 7. The resident was discovered laying on the floor by a nurse who did not treat the incident as a fall because the resident, who suffered from Alzheimer’s, told him that she just wanted to lay on the floor.
The guidance to federal regulations pertaining to nursing home falls provides that any unwitnessed incident where a resident is found on the floor should be treated as a fall. The history of having a fall is significant for at least two reasons. First is that the occurrence of a single fall is often a precursor to having additional falls. Second is that the occurrence of a fall starts the process of revising a resident fall prevention care plan and serial follow-up checks for injury. Calling a fall as something other than was it is places the health and well-being of the resident at risk.
The second fall happened on July 9. The resident was once again found on the floor by staff. The fall report completed by the nursing home documented that the resident’s roommate stated that she rolled out of bed while sleeping. However, when the roommate was interviewed by a state surveyor, she denied having said that. Further, when staff was later interviewed by the state surveyor, they told the surveyor that the fall happened when she stumbled coming back from the bathroom.
As we stated earlier, the occurrence a single fall is often the precursor to having additional falls, and this resident experienced a third fall on July 15, eight days after being found on the floor. This was another unwitnessed fall where she was discovered on the floor shortly before 8 am. By 3 pm that day she was sent to the hospital where a CT scan showed a brain bleed with a 10 mm shift of midline, indicating significant pressure on the brain from the bleeding.
After the second fall, she was care planned as being at risk for falls, with a care plan which included regular rounds, staff assistance, safety cues, call light placement.
A few impressions come immediately to mind regarding this nursing home fall:
First, the initial fall on July 7 was not documented as a fall and it is unclear whether the care planning that preceded the third catastrophic fall assumed that there had been only one fall in the preceding days or two. If the assumption was that there was a single fall, the interesting question to pose to the care plan coordinator would be whether that would have changed her approach.
Second, of the interventions that were listed, two of the four required the cooperation and participation of the resident who was suffering from Alzheimer’s. These are interventions that had no more than a hope of actually working, and hope is not a substitute for good care.
Third, the other two interventions: staff assistance and regular rounding were pretty meaningless – How frequently? What sort of assistance? The point of having a care plan is to ensure that the residents receive the care needed on a day to day, shift to shift basis and isn’t left to random chance. This care plan screams “random chance”.
Fourth, when the resident was brought to the emergency room, the CT scan showed a 10 mm shift, which means that there was significant bleeding which would have caused neuro changes much earler than when the staff acted on it. If the staff was properly doing a 72-hour fall watch, the transfer to the hospital should have occurred much earlier resulting in detection and treatment of the brain injury much sooner.
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 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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