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Report: Nursing Home Falls Precipitated Patient Death

A series of nursing home falls suffered by a patient in Minnesota foreshadowed a final, fatal fall from a wheelchair for an elderly resident last year.

Now, that nursing home, located in Duluth, has been cited for neglect.

According to news reports, the state health department alleges the center failed in its duty to comprehensively assess the high risk for falls posed to this resident, and further to reassess the risks after each incident. In fact, a state investigator found this particular patient fell 10 times between July 2014 and November 2014. Three of those falls occurred within days of each other – Nov. 17, Nov. 22 and again, finally, in Nov. 24. That last fall resulted in the resident’s death.

He was reportedly found on his back, his wheelchair several feet away. He had a large laceration on his head. He was pale and unresponsive. It’s unclear how long he’d been laying there before someone found him. Transported to a local hospital, he was diagnosed with a brain bleed. He was transported to hospice where he lived only another four days.

Following a health department investigation, the facility was cited with nursing home neglect. The facility had taken corrective action and was in compliance with state standards as of last month.

Specifically with regard to anti-fall measures, the facility enacted a number of preventative measures in the last six months. That has resulted in a 33 percent reduction in the number of falls in a three-month window, as compared to this same time last year.

That’s a noteworthy improvement. But it shouldn’t have taken a patient’s death to make it happen.

The Centers for Disease Control and Prevention reports that each year, the average 100-bed nursing home reports between 100 to 200 falls annually. Just that figure alone would indicate every resident falls at least once and some fall more than once. But that doesn’t even take into account the fact that many falls aren’t even reported in the first place.

Additionally, about 35 percent of fall injuries occur among residents who cannot walk. This is not a matter of someone slipping or tripping or losing their balance. These are individuals who are already largely immobilized – a fact known to their caregivers. With that fact understood, preventative measures are not only easily enacted, they are expected.

At minimum, the CDC recommends nursing homes:

  1. Assess each patient’s risk for falling (medical conditions, staff training, etc.)
  2. Identify and implement interventions to minimize fall risks (improve lighting, keep hallways and rooms clear of clutter, use a sitter, use of bed and chair alarms)
  3. Identify and implement interventions to minimize the risk of sustaining injury as a result of a fall (hip protectors, efficient post-fall plan for staffers)

Most centers use a method called the “Morse Fall Scale” to determine a patient’s fall risk on a scale of 0 to 51. A person whose score is between 0 and 24 has no fall risk, a person who scores 25 to 50 indicates a low to medium fall risk and a score of 51 or higher indicates a high fall risk.

The majority of falls don’t have a singular cause, but instead are predicated on a number of factors. Those who have a high fall risk should be evaluated by an interdisciplinary team to formulate a plan to minimize risks.

If your loved one has suffered injury from a fall or especially from repeated falls, it could be a sign of nursing home neglect. Contact us today to learn more about how we can help.

Freeman Injury Law — 1-800-561-7777 for a free appointment to discuss your rights.

Additional Resources:

State cites Duluth nursing facility after resident’s fatal fall, May 20, 2015, By John Lundy, Duluth News Tribune

More Blog Entries:

Report: Nursing Home Abuse Concealed by Management, May 29, 2015, Broward Nursing Home Neglect Attorney Blog

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