Holy Family Villa in Palos Park has been cited again by IDPH, this time for two serious nursing home falls. One caused a brain bleed with resulted in the wrongful death of the nursing home resident. The other caused a fractured hip.
In the first fall, the resident was assessed as a fall risk and had a care plan which called for the use of a helmet, a low bed, and floor mats. She was also on a toileting schedule which called for her to be checked on every 2 hours during sleep hours. Staff was also to do hourly checks to make sure that she was wearing her helmet, even while in bed.
On the night of her fall, she was toileted at 12:30 a.m., checked on and found sleeping at 1:30 a.m., and then there was no further documentation of her being checked on until she was found crawling on the floor at 4:30 a.m. She was brought to the hospital where she was discovered to have a brain bleed. The family elected to not have surgery performed, and she died two weeks later.
This is a situation which illustrates the use of a toileting schedule as a fall prevention measure. The resident in this case was due at least two additional rounding checks, at 2:30 a.m. and 3:30 a.m. which were not done. As a result the resident attempted to get out of bed on her own to go to the bathroom, resulting in a a fall with fatal injuries.
In the second fall, the resident was also assessed as a fall risk, and had a care plan which included the use of a low bed, floor mats, and a concave mattress. The resident’s roommate was dying, so he was temporarily moved to a different room to allow the roommate’s family some privacy. When he was moved to the different room, the staff was not made aware that the care plan included the use of a concave mattress. As a result, he was given an ordinary, flat mattress. He rolled out of bed and suffered a fractured hip.
This resident’s care plan had an effective means for preventing exactly the kind of nursing home fall that resulted in this man’s fractured hip. However, the contents of that care plan were not communicated to the nurse charged with caring for him in the room he was given on a temporary basis. As a result, the measures were not taken.
These nursing home falls demonstrate the importance of implementing the care planning process in nursing homes on a day-to-day, shift-to-shift basis. Each of these resident had plans in place which if carried out likely would have prevented the serious injuries and death of these nursing home residents. This is part of why when we prosecute nursing home abuse and neglect cases, we look closely at the care planning process as a framework for our investigation.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses 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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