In a survey performed on December 21, 2011, a state investigator discovered that there were 45 falls at Medilodge of Hillman in a 3 month period. These 45 falls happened among only 11 residents.
The state found that these falls were due to the staff’s failure to follow the residents’ written fall prevention care plans and the staff’s failure to ensure that safety measures were in place. For example, staff failed to turn alarms to the “on” position, which allowed residents to get up without alerting the staff. Staff also failed to take residents to their rooms to rest in bed when they were found asleep in their wheelchair, which resulted in the residents leaning forward and falling on the floor. On one occasion, a resident was found on the floor by the cleaning lady.
In another instance, staff failed to make sure that a resident’s call light was within her reach. The call light was to be within her reach at all times so that she could request staff assistance when she needed to get out of bed because she had an unsteady balance. It was noted that the resident usually used her call light. However, at 1:00 a.m. on November 12, 2011, the call light was not within her reach. As a result, when she needed to use the bathroom, she was unable to call for help. She attempted to get up on her own and fell, striking her head. After the fall, the resident had seizure activity and was later taken to the Emergency Room. She was diagnosed with a brain bleed.
The Director of Nursing admitted that the call light is “absolutely” required for all residents.
Medilodge of Hillman was also cited for failing to demonstrate that the nursing assistants received timely and appropriate training related to resident falls.