Minnesota DOH Substantiated Allegation of Neglect in Nursing Home Resident’s Fall
After receiving an allegation of neglect regarding an immobile resident’s falling and fracturing her arm, the Minnesota Department of Health (DOH) investigated the incident. The DOH substantiated the allegation of neglect in a report issued last December.
The resident has Alzheimer’s disease and is unable to walk. She fell off the side of her bed after a staff member left her unattended. The staff member delayed reporting the fall for about an hour and disregarded the resident’s care plan by picking up the resident without using the mechanical lift. She also initially lied about the fall and did not admit the truth until a day later.
When the staff member was questioned, she admitted that the fall happened after she dressed the resident and left her sitting on the side of the bed while she went across the room to get the mechanical lift. The staff member said that she became scared of getting into trouble when the resident fell and so did not tell the truth about what happened.
The staff person continues to work at the facility after being disciplined and re-educated. She is being monitored periodically.
A representative from the facility reported that it had conducted an internal review and followed that up with new protocols and policies along with additional training.
Compliance Perspective
Failure to ensure that residents’ care plans are followed regarding the use of a mechanical lift or a specific number of persons to move a resident and the failure of a facility’s staff member to report a fall may be considered neglect and provision of substandard quality of care
Discussion Points:
- Review policies and procedures regarding following residents’ care plans and monitoring residents at risk for falls.
- Train staff to follow residents’ care plans and to identify what constitutes abuse and neglect.
- Periodically audit the care plans of residents at high risk for falls to determine if they are up-to-date and being followed.
