Two Illinois Nursing Homes Fined for Residents’ Injuries from Falls
Failure to prevent fall-related injuries to residents may result in substandard quality of care and the submission of a false claim
Compliance Perspective – Falls
Policies/Procedures: The Compliance and Ethics Officer with the Director of Nursing will review policies and procedures involving fall risk assessments and the implementation of intervention and prevention protocols.
Training: The Compliance and Ethics Officer with the Director of Nursing will ensure that staff are trained to conduct comprehensive fall risk assessments and demonstrate competency in implementing the protocols for intervention and prevention of falls.
Audit: The Compliance and Ethics Officer with the Director of Nursing should personally conduct an audit by reviewing the fall risk assessments of residents and their fall histories to determine the impact implementation of the intervention and prevention protocols has had on reducing repeated falls.
The Illinois Department of Public Health (IDPH) recently issued a report assessing fines of $25,000 each against two nursing homes for “failure to prevent fall-related injuries among their residents in the previous year.”
One of the incidents involved a fall in September when a 104-year-old resident broke her leg and experienced bleeding in her brain. When a nurse aide found the woman on the floor next to her bed, the aide put the resident back to bed, reported to the nurse that the woman had leg pain, but did not report the fall. Before the nurse was able to examine the woman, the aide dressed her for the day and moved her from her bed to a chair. The resident’s care plan required staff to use a lift involving two staff in order to move the resident from bed to chair, and this was not done. After the nurse examined the resident, she was sent to the hospital emergency room. The resident was diagnosed with a leg fracture above the knee and a “tiny subarachnoid hemorrhage” on the left side of her brain.” The resident was returned to the facility two days later and was placed on hospice care.
The nursing home received a citation for a “Type A” violation which is associated with conditions that may result in probable death or serious harm. The facility accepted responsibility and paid $16,250 to settle the incident. In another “Type B” violation, the facility was fined $2,200. The facility also accepted responsibility, and the fine was reduced to $1,430.
Another incident involved a different facility in the same geographic area and a 74-year-old resident suffering from memory and cognitive deficits related to Parkinson’s disease. This resident had been assessed at high risk for falls. The resident fell and received a laceration that required staples, and in another incident the resident fell, fractured his hip, and required surgery.
The IDPH found the second facility did not take the necessary precautions to “assure that the facility residents’ environment remained as free of accident hazards as possible.”
The attorney for this facility declined to respond to either the fine or to the IDPH report.
