An 82 year old male who, during a rehabilitative stay following treatment for back spasms, suffered two falls in the middle of the night, one on October 1 and a second fall on October 2. The second fall resulted in a brain injury. He suffered bleeding in the brain which caused pressure, which had to be relieved by surgically boring holes in his skull. He was hospitalized for nearly 6 weeks and spent another 6 weeks recuperating from treatment and complications from the falls at another nursing home, before he was able to return home. He required a feeding tube, had wore diapers, he had to regain strength to walk and care for his own needs.
Nursing homes charged with a responsibility to assess a residents "risk" for falling and then to take reasonable steps to both (1) minimize the risk of falling and (2) minimize injury in the event of a fall. In this case, the patient was undoubtedly a high fall risk, given his back spasms and the use of pain medications. However, the facility failed to assess him as "high" risk. Accordingly, the resident was not provided with a fall-related care plan (a set of documented actions nursing will implement to resolve problems identified by assessment and re-assessment) indicating what safeguards the nursing staff should take to prevent falls and/or to prevent or minimize injury from falls.
In this case, the resident tried to get up to go to the bathroom in the middle of the night when he suffered his first fall. This put the facility on notice that the patient would attempt to get up unassisted. Once on notice, the facility needed to take steps to keep him safe. Such steps might include lowering the bed to the floor, pushing it up against a wall so there is only one side to get in and out of the bed, putting a pad on the floor next to the bed to cushion a patient if they fall, padding the corners of the furniture and other hazards, using siderails while the patient is in the bed to make it difficult to get up unassisted, using pressure pads in the bed that alarm and alert nursing staff when the patient shifts weight in an effort to get out of bed, implementing a frequent toileting schedule (offering assistance to the bathroom or a bedpan every hour or two in the nighttime), use of a bedside commode (so the resident doesn't have to walk very far to the bathroom, particularly in the night). These are just examples of the types of interventions that keep nursing home residents safe. Acceptance of the axiom that "old people fall" is not the norm.
Unfortunately, in this case, the types of interventions outlined above were not implemented after the first fall, and the next night the patient predictably got out of bed in the early morning hours to go to the bathroom and fell again, suffering a severe brain injury. He has yet to return to his prior level of function. Even after 12 weeks in the hospital and a rehabilitation facility, he requires assistance with his activities of daily living at home even now.
Falls are a common problem in nursing homes. The Department of Public Health has issued Class AA citations over the past year to include:
In August 2010, a Class AA citation and $100,000 fine was issued against Browning Manor Convalescent Hospital in Delano, California, when a 58-year-old resident fell from his wheelchair and a fatal spinal cord fracture. The facility had been on notice that the resident would disconnect his self-release belt on his wheel chair and facility policy required one-on-one monitoring, but the facility failed to follow its own policy.
In May 2010, a Class AA citation and $100,000 fine was issued against Pilgrim Haven Health Facility when an 85 year old resident who had a history of falling fell and suffered a fatal head injury. The facility was cited for failing to monitor and supervision prior to the fall, and failure to assess and response to his injuries after the fall.
In March 2010, a Class AA citation and $100,000 fine was issued against Golden Living Center in Shafter California when a patient, who had a history of falls, fell and suffered a fatal head injury. The patient was taking a blood thinner, which carries great risk of fatal bleeding if an elder falls. Unfortunately, the physician monitoring her medications was not told that she was falling frequently and he was not involved in developing her care plan or changing her medications. The facility's director of nursing told the investigator, "Residents have the right to fall." This statement is specious and was flatly rejected.
In February 2010, a Class AA and $100,000 fine was issued against Villa Rancho Bernardo Care Center in San Diego when a resident fell down a concrete stairwell while still secured in his wheel chair, sustaining fatal blunt force trauma to his head and torso. The facility was cited for failing to supervise the resident despite a history of wandering and exit seeking behaviors
In January 2010, a Class AA and $100,000 fine was issued against Bakersfield Healthcare Center when a 99 year old resident fell after getting out of bed, was found on the floor bleeding, and suffered a fatal head injury. The facility failed to implement a fall risk plan and failed to address her safety needs. Also in January 2010, a Class AA citation and $85,000 fine was issued against Kindred HealthCare Center of Orange when nursing staff failed
On September 29, 2010, the Law Offices of Jody C. Moore, APC filed in Ventura, CA County Court, a civil suit for Violation of Resident's Rights, Elder Abuse, Willful Misconduct, Negligence and Loss of Consortium against Five Star Quality Care CA II - LLC involving the care and treatment received by plaintiff at their facility, Thousand Oaks Healthcare Center, in Thousand Oaks, CA. Plaintiffs are suing for, among other things, the facilities failure to care plan for this knowingly high fall-risk patient, failing to minimize fall risk hazards, and for failing to report his change in condition following his second fall.
