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Cass County Medical Care Facility cited as a result of three residents falling in one month

Cass County Medical Care Facility was cited in November of 2011 for serious violations concerning its inability to keep three of its residents safe from falls.  After conducting an investigation, state surveyors found that the facility: (1) failed to follow care plan interventions, (2) failed to conduct walking rounds timely; and (3) failed to provide adequate supervision to prevent falls.

The first resident, Jane Doe, suffered a fall at 7:20 a.m. on November 7, 2011, when the staff failed to remove the soft mat next to her bed after she was placed in her wheelchair.  The purpose of the mat on the floor was to prevent Jane Doe from injuring herself if she fell out of bed.  The mat was supposed to be removed when Jane Doe was out of bed so that she didn’t trip over the mat.  Interviews of the staff assigned to Jane Doe, however, revealed that the nursing assistant who transferred Jane Doe to her wheelchair did not pick up the mat.  Interviews also revealed that a second nursing assistant saw Jane Doe in her wheelchair and saw the mat on the floor in her room, but did not pick up the mat.

A nurse told the state investigator that the incoming nursing assistants were required to visualize all residents assigned to their care who were identified as “at risk for falls” during walking rounds at the change of shift and ensure all safety devices were in place and in working order.  The nursing assistants assigned to Jane Doe, however, admitted that they did not do rounds at the start of the shift on which Jane Doe fell, nor did the nursing assistant who was starting her shift actually visualize Jane Doe and check that her personal alarms were in place and working.  The nursing assistants claimed to be “too busy” to perform these duties.

One nursing assistant actually blamed Jane Doe for unfolding her mat and placing it next to her bed; another nursing assistant, however, admitted that Jane Doe was physically unable to do so.

Because the nursing assistants failed to do their jobs, Jane Doe tripped over her mat and was found by the staff partially seated on her wheelchair with her knees on the mat with her left arm behind her crying and screaming out in pain.  The nursing assistant who found Jane Doe pulled her left arm, which was stuck behind her back, to the correct position and lowered Jane Doe to the floor.  An x-ray revealed that she sustained a displaced fracture to her upper left arm.

The second resident, Mary Doe, suffered a fall at 8:05 a.m. on November 27, 2011, when the staff failed to use a personal alarm as required.  Mary Doe had dementia and significant cognitive deficits.  As a result, an alarm was supposed to be utilized while Mary Doe was in bed to alert staff in the event that Mary Doe attempted to get out of bed without assistance.

A nurse at the facility told the state that both the off-going and the on-going shift aides were responsible to ensure alarms were in place and in working order at the change of shift.  The state was unable to contact the nursing assistant who was assigned to care for Mary Doe on the off-going shift.  The nursing assistant assigned to care for Mary Doe on the on-going shift, however, admitted that she did not visualize Mary Doe at the start of her shift, nor did she check to ensure that Mary Doe’s personal fall alarm was attached and in working order prior to the fall.

Because the nursing assistants failed to do their jobs, Mary Doe was able to get out of bed without an alarm sounding.  As a result, no one knew to come to her aid and she fell on the floor.  Her roommate heard her fall “pretty hard” and pushed her call light.  When a nursing assistant finally arrived, Mary Doe was found lying on the floor with blood on the floor, with an abrasion on her head and her right leg was painful and shorter than her left leg.  Mary Doe was taken to the Emergency Room, where she was found to have a fractured hip, which required surgical repair.

The third resident, Sue Doe, suffered four falls in the month of November as a result of being allowed to improperly use her walker.  In once instance, a member of the maintenance staff actually observed Sue Doe leaning over her wheelchair, rubbing the wall and circling the nurse’s station at a quick pace.  Despite there being two staff persons at the nurse’s station, the maintenance staff member had to bring this unsafe behavior to the staff’s attention.  Sue Doe’s multiple falls resulted in bruises and a laceration requiring sutures.