Law-Den Nursing Home received several citations for failing to provide fall and accident intervention resulting in death or injury.
On September 13, 2011 a resident died in the hospital after falls resulted in two broken leg bones. The resident was not being supervised at the time of the fall and there were no safety devices in place to prevent falls. The resident was diagnosed with dementia, did not walk and relied on staff for all aspects of daily living. The DON stated that “close supervision” was the intervention to ensure safety, and even though personal alarms are used, this resident was not outfitted with one after a fall from her wheelchair. The DON could also not explain why telling a person with dementia to wait for assistance is an effective safety intervention.
The incident report stated that the resident had fallen twice when not supervised by staff, resulting in broken legs and transfer to the hospital on September 9, 2011 where the resident died three days later.
In another serious incident on March 22, 2011, one resident was injured in a fall due to an incorrectly recorded care plan. The CNA’s care guide stated the resident needed only one person to assist with transfers when in fact two were required. The resident was a high risk for falls due to severe cognitive impairment, her left leg was amputated and she could not walk on her own. One CNA tried to move the resident, her foot became tangled in the Geri-chair then stuck. The resident was injured with a multiple fractures to her ankle and required hospitalization. The director of nurses (DON) and facility administrator could not explain why the CNA’s handbook stated one person was enough for transfer when all other documentation indicated the resident would need two CNA’s for a safe transfer. Also, they couldn’t explain why the information in the CNA’s care guide was not updated after the resident suffered injuries due to this mistake.