An Illinois nursing home was named in a lawsuit alleging the staff’s negligence resulted in a resident’s fall. The plaintiff, acting as independent administrator of the estate of the resident, filed the lawsuit, citing negligence.
According to the lawsuit, when the resident was admitted to the nursing home, the staff were told that she was at risk for falls, had dementia, and was almost completely blind. It was also made known that her room was supposed to remain unlocked so proper care could be provided.
The lawsuit alleges that at 1:45 a.m. the next day, an employee heard the resident yelling from the room, but couldn’t open the door. The employee looked through the window and saw that the resident had fallen. When nursing staff finally got the door open, the resident complained of leg pain. She was taken to the hospital and diagnosed with displaced right femoral neck fracture. She then underwent a procedure to address the injury. The resident was taken to a different facility, where she lived for two months in pain as a result of the injuries she suffered at the first nursing home. The suit states that prior to her death, her medical treatment to address the injury cost her substantial amounts of money.
According to the lawsuit, the nursing staff at the first nursing home had not performed their required duties to properly prepare the resident for bed prior to her fall. The plaintiff is seeking damages.
Issue:
F689 states that the resident environment must remain as free of accident hazards as possible, and each resident should receive adequate supervision and assistance devices to prevent accidents. The requirement includes identifying and evaluating hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. If a fall occurs, the resident must be assessed thoroughly, and the plan of care updated to reduce the likelihood of future falls. The physician should be notified promptly of all falls, and if a change in condition occurs, the physician must be notified immediately. Failure to prevent falls can be considered provision of substandard quality care, and may result in an immediate jeopardy citation, fines, and lawsuits.
Discussion Points:
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting and documenting incidents/accidents to ensure they meet current requirements.
- Train all appropriate staff on resident safety policies and procedures, documentation, and reporting requirements. Document that the trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit care plans to ensure that they are appropriate, person-centered, and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes. Audit your incident/accident reports to ensure that all issues where reporting is required were managed timely with appropriate follow-up, and that documentation is complete.
