Failure to follow recommendations leads to fall and facial fractures at Tower Hill

IDPH has cited and fined Tower Hill Healthcare in Elgin after a resident fell and suffered facial fractures.

Care planning is intended to be a multidisciplinary, ongoing process where the staff develops a series of measures intended to assure the safety of residents. Because nursing home falls have such serious consequences for residents, this is one area which is specifically care planned.

Care planning is a six step process. It starts with the assessment, which identifies risks to the health and well-being of residents. From there, the actual care plan is developed which is a series of measures or interventions which must be taken by particular disciplines within the nursing home on a day-to-day, shift-to-shift basis. Once the care plan is developed, it must be communicated to the staff charged with carrying it out. It must then be implemented on an ongoing basis. Finally, it must be evaluated for effectiveness on an ongoing basis and revised if it proves ineffective in practice or there are changes in the resident’s condition. This is actually a part of the framework we use when investigating and prosecuting nursing home abuse and neglect cases.

The resident at issue was properly assessed as being a fall risk. This was due to a number of factors including confusion, poor safety awareness, and gait abnormalities. Her fall prevention care plan included having physical therapy evaluate and treat the resident. When she was discharged from physical therapy, there were recommendations made by physical therapy which included having hand hold and contact guard assist while walking. Contact guard assist means that there is a staff member literally holding onto the resident by a gait belt while the resident is walking.

The recommendations made by physical therapy were not a part of the resident fall prevention care plan at the time of her discharge from physical therapy. Unfortunately, it did not become part of her care plan until after she had the fall which sparked this investigation by IDPH.

On the day of the fall, the resident an aide were walking down the middle of the hall together. The aide was not employing a contact guard assist for this resident – in fact, she just happened to be going to down the hall at the same time as her, not ever thinking that the resident required any additional assistance. And in the aide’s defense, there was no reason for her to think so because the need to use that had never been incorporated into the resident care plan or communicated to her that this was needed.

The aide went into another room and a few minutes later heard the resident calling for help. She came out to find the resident on the floor with a large gash in her forehead. The resident was sent to the hospital when the doctors diagnosed several facial fractures.

This is a case where the data was available to keep this resident safe, but it was never included in the resident care plan because of a breakdown in the system. This resident was sent to physical therapy for the express purpose of getting treatment and evaluations, and the information that was developed during the course therapy was never put to use.

As you read the citation, it appears that the electronic charting system that they use at this nursing home played a role in the failure of the recommendations of physical therapy to make their way to the floor. Broken systems have much larger implications than any one particular incident. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

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