Two Residents in Two Pennsylvania Nursing Homes Die from Falls
The Pennsylvania Department of Health (DOH) recently reported the deaths of two nursing home residents in two different facilities. Both of the deaths were due to falls sustained when staff members failed to follow the required 2-person transfer orders. The coroner determined that both of the deaths were due to traumatic neck injuries.
In one of the deaths, the aide who transferred the resident did not follow the resident’s care plan for being transferred and also violated another regulation by not reporting the incident to the supervisor. Instead, the aide claimed that the resident was found in bed bleeding from the head. The DOH report indicated that although the resident’s injury was treated, the resident was found unresponsive later that day.
The report also indicated that the nursing home held several meetings to train/educate staff that were part of the plan of correction that also included follow-up reviews after one and six months.
The staff at the other nursing home responded to the fall immediately, but the resident died an hour later. The nursing home issued a statement expressing its concern about the incident.
A follow-up survey by the DOH concluded that the nursing home where the second death occurred, “successfully implemented the approved plan of correction.” The plan included education and audits.
Compliance Perspective
Failure to ensure that residents’ care plans are followed regarding the need for two-person transfers, failure by staff members to report residents’ falls, and the deliberate deception by any staff member in the circumstances of a resident’s injury may be considered neglect, immediate jeopardy of resident safety, and provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the implementation of required transfer policies for residents by staff members.
- Train staff to follow residents’ care plan transfer instructions, abuse and neglect prevention requirements, and mandatory reporting of incidents to a supervisor or through the Hotline.
- Periodically audit residents’ care plans and transfer policies and observe to determine if staff members are following those protocols.
