We reached a settlement on behalf of a nursing home resident who suffered a fractured hip when the elements of her fall prevention care plan were not carried out.
The resident suffered from advanced Alzheimer’s dementia and was properly assessed as being a fall risk due to her gait abnormalities, confusion, medication usage, and incontinence. The care plan that was put into place for her included: (1) placing her in front of the nursing station after she is dressed but before breakfast was served and (2) use of a pad alarm for her wheelchair. The reason that she was to be placed in front of the nurse’s station is so that she could be kept under direct observation by the nurses during early morning hours when she had been observed trying to walk unassisted. The pad alarm is a pressure sensitive device which sounds when the weight of the resident is removed from the sensor strip.
On the morning of her injury, the resident was dressed and brought out in front of the nurse’s station as called for in the care plan. However, she was able to get up unassisted and walk the length of the hallway to her room where she was discovered an hour later on the floor with a broken hip. No one at the nurse’s station was aware that she had gotten out of her chair, and the alarm did not sound because the batteries were dead and had not been replaced.
The failure to carry out two elements called for in the care plan resulted in the resident falling and suffering a fractured hip. First, even though she was supposed to be kept under direct observation, she was able to get up unattended and walk the length of the hallway to her room. Secondly, even if the staff did not see her get up, a working alarm would have alerted the staff that she was up, but the alarm did not work because the batteries were dead.
Following the fall, the resdient’s Alzheimer’s dementia advanced rapidly and she as not able to walk again following her fall.