IDPH has cited and fined Rosewood of Elgin nursing home after a resident there suffered fatal injuries in a fall from his wheelchair.
The resident at issue suffered from dementia and required extensive assistance with his activities of daily living and required the assistance of two staff members for transfers with a mechanical lift. He was wheeclchair bound and had been assessed as a fall risk by the staff due to balance deficits and inadequate safety awareness. He also had a history of prior falls.
As is a recent trend, the nursing home had elected to stop using bed alarms and mobility alarms as tool to help prevent nursing home falls, instead relying upon supervision of residents by the staff as a means of preventing falls. The practice at that facility had been to place residents who were fall risks at the nurse’s station for observation by the staff while they were charting.
Typically, the residents at risk for falling would be placed behind the nurse’s station and in view of the nurses so that the staff could assist them while doing work at the nurse’s station. That morning, this resident was placed on the far side of the nurse’s station because the staff was all behind the nurse’s station having their morning meeting. Another nurse was walking down the hallway and saw that the resident was sitting in his wheelchair with a bowl filled with cereal in his lap. She noticed that he had spilled some of the cereal and that he had had an episode of incontinence. She instructed an aide to clean him up and proceeded to her meeting.
A few minutes later, a visitor to the facility saw the resident leaning forward and shouted “He’s going to fall!” The staff at the meeting tried to reach him, but he fell forward out of his wheelchair, striking his forehead on the floor.
He was brought to the hospital, where a CT scan showed that he suffered a burst fracture at the C6 level. A neurosurgeon was brought in, but he determined that surgery could not be done. The resident died the next day due to respiratory compromise brought on by the spinal fracture.
Many nursing homes are doing away with bed alarms and mobility alarms as a fall prevention measure. Alarms were – and in my opinion, are – a good tool to alert staff that a resident who is at risk for falling is getting up unattended. It is was a part of the focused, systematic effort at fall prevention that was at the heart of many fall prevention care plans.
Federal regulations were updated and changes took effect in late November, 2017, but the basic federal regulations pertaining to falls in nursing homes have not changed – nursing homes are required to provide supervision and assistive devices necessary to prevent falls. However, without alarms, nursing homes must have a systematic, routinized way of providing supervision to residents on a 24/7 basis without having the information that the alarms provided as to what residents needed it at a particular moment.
If nursing homes are going to discharge their obliagtion to provide supervision necessary to prevent resident falls, in practice that means that they are going to have to get more eyes on the residents …. and that means more staff. I believe that if a nursing home has given up using alarms as fall prevention measure and don’t have more staff on the floor, they are truly understaffed in terms of meeting the requirements of the federal regulations which require them to have sufficient staff on hand to meet the care needs of residents on a 24/7 basis and to provide adequate supervision to prevent falls.
Indeed, review of the citation relating to this nursing home wrongful death reveals that at least some of the staff feel that same way, as they describe having reported to management that they needed additional staff once the alarms were removed from the facility.
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