Articles Posted in Nursing Home Falls

Ninety-two-year-old Robert Doscher was admitted to Valley Gardens Health Care, a for-profit nursing home, on May 18, 2007. He came from a hospital where he was being treated for a mini-stroke, and other heart issues. Upon admission to the nursing home, he needed the use of a walker, and the plan was to stabilize his health, and transfer him to an assisted living facility.

He required the use of a walker when he was admitted, and it was initially planned that he could be discharged to a board-and-care facility when his condition stabilized. The admission assessment at Valley Gardens determined that Doscher was at “high risk” for falling, and the care plan ordered the he be checked “every one to two hours.” He was also instructed not to get up without assistance, and a tab alarm was placed on his clothing to monitor his movements.

On May 21st, only three days after he was admitted to the nursing home, Doscher fell and struck his head on the floor. He was found by staff on the floor. According to the investigation, there was no evidence that Valley Gardens was checking on Doscher every one to two hours, nor did they place him near the nursing station, as had also been recommended upon admission.

A nursing home called Valley Gardens Health Care and Rehabilitation in Stockton, California has received an “AA” citation from the California Department of Public Health due the neglect of one of its residents. The AA citation is the most severe penalty that can be levied by the state, and is issued only when a patient’s death has occurred in a way that can directly attributed to the conduct of the facility. A $90,000.00 fine was also issued.

According to news reports, which are currently scant on facts, the facility failed to ensure a resident was adequately supervised, resulting in a serious fall, which caused the resident to die.

The California Department of Public Health has the statutory authority license and certify all of California’s nursing homes. Part of its authority is to inspect the homes annually, and respond to consumer complaints. If investigations into substandard care are substantiated, the CDPH has the authority to issue citation, and impose fines. Typically, the fine depends on the significance and severity of the substantiated violation.

Tri-City Hospital in Oceanside was fined $25,000 by the California Department of Public Health for “failure to ensure the health and safety of a patient” who fell out of bed and fractured her hip. The hospital has modified its policies as a result.

According to reports, a 91-year-old woman who was admitted to Tri-City on December 7, 2008 because of a stroke, and paralysis on her right side, fell out of bed two days later and fractured her hip. She was taken to surgery for repair of the hip, and died the following day in the ICU.

The state investigation revealed that upon admission to the hospital the woman was rated as a high risk for falls; a rating that would require a series of interventions such as bed alarms, padding on the floor around the bed, etc. The investigation revealed that “there was no evidence in the medical record to support that these interventions were in place at the time (the patient) fell.

State investigators issued a $100,000 fine to nursing home Aviara Healthcare Center in Encinitas after finding that a resident’s death was caused by neglect. The resident died of blunt force trauma after a fall.

According to reports, the resident was at the nursing home to rehabilitate a broken hip, and suffered a fall on May 9 when trying to get out of bed. The following morning at 3 a.m., the resident got out of bed and stumbled into the hallway. A nurse saw him grab onto a large Hoyer lift (a large mechanical lift), which toppled over on top of the resident. The lift struck him in the head, causing a deep cut and a severe brain injury. He died three days later.

Investigators concluded that Aviara Healthcare was negligent for storing the large mechanical lift in the hallway outside the resident’s rooms, and received statements from several employees who stated that the lift was supposed to be stored elsewhere. As a result, a Class AA citation was issued.

A Westlake nursing home called Lakewood Manor North was issued the state’s most severe fine after an 83-year-old resident died in January 2007.

According to reports, the patient, who was totally dependent on staff, lost his balance and fell when he was being transferred to his wheelchair, striking his head on a bed rail. Shortly after his fall, nurses noted bluish discoloration on the left side of his head. His condition continued to decline throughout the day, and the man complained of not feeling well. During the evening, after consulting with a physician, the man was transferred to a local hospital at 9:30 p.m., where he was diagnosed with severe bleeding on the brain. He died five days later.

Investigators with the California Department of Public Health faulted the nursing home for failing to take action earlier, when it was clear the resident was suffering a significant change in condition.

Every year the typical nursing home will report approximately 1.5 falls per bed, and most falls go unreported. In fact, studies show that 75% of nursing home residents will fall at least once in a year, and nearly one-third of those involve a resident who is deemed non-ambulatory. Sadly, approximately 1,800 people living a nursing facility die every year due to a fall.

Can falls be prevented? Yes, and they should be. With proper care planning, many if not most falls can be prevented in the skilled nursing setting. For example, each resident must be accurately assessed on a regular basis for risk of falling, and when there is a fall, proper assessment must be performed to determine the cause of the fall, and how another might be prevented in the future.

In addition, physical changes in the nursing home can help prevent falls, including the placement of grab bars, lowering beds, and raising toilet seats. Bed alarms can also prevent a fall in a resident who is a known risk.

Last week President Bush signed into law the Safety of Seniors Act, a bill dedicated to preventing injuries of the elderly inside the home. According to the CDC, one in every three Americans over 65 will suffer a fall their home, and nearly a third of those will require medical treatment. In addition, 80% of elderly Americans who suffer a serious fall will suffer an additional fall within a year.

The bipartisan legislation seeks to develop educational strategies to increase the awareness of falls, support research to identify populations at risk for falling, and encourage projects that promote fall prevention. In California, health officials say they will make fall prevention a major priority starting this summer.

According to the CDC, almost $20 billion dollars is annually on medical costs related to elderly falls, most of which is paid for the Medicare and Medicaid. Because of the aging baby boomers, that figure is expected to rise to $43 billion by the year 2020.

The signs and symptoms of a brain injury are not always as clear as you might think. Most patients who suffer a traumatic brain injury can walk, talk, and give the appearance of a normally functioning person. There are, however, symptoms that point to brain trauma.

The month of March is set aside to increase the awareness of traumatic brain injuries, which can be caused by a bump, blow, or jolt to the head. The Centers for Disease Control and Prevention reports that falls – particularly in people over age 75 – are the leading cause of brain injuries in the United States.

Those who care for the elderly should be aware of the symptoms of a brain injury. In a mild injury, a person might have a persistent headache, confused, or have blurred vision. Another symptoms is a lost of smell or taste. A more severe injury may cause vomiting, slurred speech or weakness in arms or legs.

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