Nursing Home Falls

Unfortunately, falls in older people are common.  But many falls are preventable if a nursing home is willing to spend the money to properly staff a facility.

In this article, we’ll cover nursing home fall statistics, how to investigate and prosecute a nursing home fall lawsuit, and how to find a nursing home fall lawyer.

Nursing Home Falls are Common, and Deadly

According to the Centers for Disease Control and Prevention, about 1,800 older adults living in nursing homes die each year from injuries related to falls, such as broken bones and head trauma.[i] Given that only about 10% to 20% of nursing home falls cause serious injuries, and only 2% to 6% cause fractures, the reality is that far too many older Americans are falling in nursing homes.

This is not limited to nursing homes, either.  The Agency for Healthcare Research and Quality found between 700,000 and 1 million hospital patients fall each year. Between 30% and 51% of those patients suffer a serious, “reportable” injury.[ii]

When a nursing home resident falls, the result can include traumatic injuries, disability, functional decline, and reduced quality of life.  What’s worse, the resident may now have a much more severe fear of falling that can cause depression, additional functional decline, a sense of helplessness, or isolation.

Are Nursing Home Resident Falls Preventable?

Yes. The Centers for Disease Control and Prevention has identified a number of things nursing homes can do to help prevent falls, such as reviewing prescribed drugs to assess their risk (some drugs can make a person dizzy, disoriented, or lose their balance), installing grab bars so the resident is able to steady their self, and better training for nursing home staff.

A resident fall can be a sign of other health problems the resident may have.  People in nursing homes are generally frailer than older adults living in the community.  They may have more chronic conditions, more difficulty walking, and need a higher level of care.  They may also have thought or memory problems, need assistance with activities of daily living (things like getting dressed, grooming, and hygiene), or need help getting around.

All of these factors are linked to an increased risk for falls.[iii]  It is a nursing home’s job to identify, assess, and respond to these risks to minimize the chance of a fall.  When a nursing home does not do its job, and as a result, the resident is injured in a fall, the nursing home should be held accountable for the harm that results.

What are the Most Common Causes of Nursing Home Falls?

The Centers for Disease Control and Prevention has collected and reviewed research regarding nursing home resident falls, and concluded the following factors are the most common causes of nursing home falls:

• “Muscle weakness and walking or gait problems are the most common causes of falls among nursing home residents.”
• “Environmental hazards in nursing homes,” including “wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.”
• “Medications” that “increase the risk of falls and fall-related injuries.”  This includes sedatives and anti-anxiety drugs, which can affect the resident’s cognitive ability or balance.  It is not just taking the medications, but changing them, that can present a serious risk of falls: “Fall risk is significantly elevated during the three days following any change in these types of medications.”
• Problems with walking or transferring, such as “difficulty in moving from one place to another (for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.”

How Can We Prevent Falls In Nursing Homes?

When it comes to preventing nursing home falls, there are three levels to consider:  fall prevention interventions implemented at the organizational, staff or patient level.

While families tend to consider only the patient level—is the nursing home providing the resident with appropriate care to prevent a fall?—there can be a breakdown at the organizational or staff level that makes providing adequate care difficult or impossible.  It doesn’t matter if the right interventions are in place if the staff caring for your parent does not get the information, training, or time needed to implement them.

I most often have cases involving that type of breakdown: the right interventions on paper, but the staff was not given the message, or the opportunity, to properly implement them.

Fall interventions include:

• Educating and training nursing home staff to understand fall risk factors and prevention strategies.
• Improving the nursing home environment to make it easier for residents to move safely, such as grab bars, raised toilet seats, lower-height beds, and hallway handrails.
• Assessing prescription medications for the potential risks of falling, and ensuring minimal use to accomplish the medical goals.
• Assessing resident fall risk thoroughly and regularly.
• Assessing what happened and how to correct the issue after a nursing home resident fall to improve the system and the resident’s underlying medical conditions.
• Nursing home resident exercise programs to improve balance, strength, walking ability, and physical functioning.
• Tool such as bed and wheelchair alarms, floor mats, two-person assists with transfers and bed mobility, non-slip footwear.

Notably, routine use of restraints does not lower the risk of falls or fall injuries, and are not considered a fall prevention strategy. As the Centers for Disease Control and Prevention explains:

• “Limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function.”
• Most nursing homes “have seen a drop in fall-related injuries” since anti-restraint regulations were implemented.
• “Direct injury from bedrails appears to be due to outmoded design or incorrect assembly; bedrails do not appear to increase the risk of falls or fall injuries.”[iv]

Does a Resident Fall Mean a Nursing Home was Negligent or Neglectful?

If a resident falls and is seriously injured in a nursing home, the nursing home is responsible if the fall occurred because it:

• Failed to properly evaluate the resident’s risk of the resident falling
• Failed to provide adequate assistance to address the risk of the resident falling
• Dropped, pushed, rolled the resident out of bed, or abandoned the resident in a situation in which the resident should not have been left alone (such as in a chair or on the toilet when the resident has poor sitting balance)
• Hired unqualified employees or provided insufficient training
• Failed to develop an adequate care plan based on the resident’s condition and needs
• Failed to regularly reassess and modify the resident’s care plan
• Failed to provide care in accordance with the resident’s care plan

Every nursing home that accepts Medicare payments must follow the Federal Regulations regarding caring for nursing home residents, 42 CFR sec. 483 et seq.  Under these regulations—and there are Ohio nursing home counterparts—require facilities to “ensure that  . . . [t]he resident environment remains as free of accident hazards as possible; and [e]ach resident receives adequate supervision and assistance devices to prevent accidents.”

Federal nursing home regulations and their Ohio counterparts also require nursing homes to provide every resident with an assessment done when they enter the facility, and regularly updated thereafter, including whenever there is a significant change in a resident’s medical condition.

This assessment must include a written plan of care (“care plan”) which describes the functional capacity of the resident and their fall risk.  The nursing home must take appropriate action to address those risks, such as supervise the resident and provide safety devices to prevent fall injuries.  That means full consideration of the resident’s health issues, including:

• Mobility limitations
• Loss of strength or balance
• Medications that can cause dizziness, drowsiness, or poor reaction time
• Dementia or other cognitive limitations, and
• Impaired vision or dexterity.

The care plan should also include any assistive devices necessary to provide adequate care to the resident and keep them reasonably safe from falls, including:

• walkers and other mobility aids
• assessment of safe height for beds, chairs, and toilets
• positioning of grab bars and rails

If the nursing home fails to comply with these or any of the myriad other regulations, and a resident is injured, the nursing home is responsible for the harm that results.

We’re lawyers who sue nursing homes for things like preventable resident falls.  If you would like to discuss your loved one’s situation, injuries, or death at a nursing home, call us at 216-777-8856.

How Do You Prove Nursing Home Neglect or Negligence Caused a Resident Fall?

It can be difficult to prove exactly how a fall occurred without an attorney experienced in nursing home fall cases.  This is not simply a slip-and-fall case.  There are specific state and federal requirements for assessing and addressing nursing home resident fall risk.

Some of the sources of evidence I use when investigating and building the case in a nursing home fall include:

• Physical and occupational therapy records. (How much physical or cognitive assistance did the resident need to walk, stand, transfer, brush her teeth, etc.? Was she needing more or less assistance over time?  How was this being communicated to nursing staff?)
• Nutritionist and social worker notes.
• Video and photographic evidence—which can require a fight to get, including visiting the scene to establish what cameras exist and what they saw.
• Other residents’ as witnesses of the fall, the resident’s abilities and needs, nursing home staffing levels, etc.
• Current and former nursing and physical therapy staff members.
• The nursing home’s history of fall and other resident injury events.
• The nursing home’s financial and staffing picture. (Was it, or the national chain parent, putting profits above patient safety?)
• The nursing notes and nursing aide records showing who did what, when (or, at least, what they say they did).
• Family and friend knowledge.
• State Medicaid and Federal Medicare records, rules, and regulations.
• Deposing the Director of Nursing and Administrator, and often corporate representatives up the chain of command that really control the purse strings and staffing levels.
• The resident’s memory or statements, if they survived and were lucid. (I’ve seen highly suspect “statements” attributed to a resident after a deadly head trauma the resident was likely unable to make.)

Every nursing home fall case is different, but nursing homes are all too often the same: putting money into profits instead of adequate care, usually by cutting staff and staff pay (resulting in high staff burnout, turnover, stress, and mistakes).

Nursing Home Fall Lawsuits

Suing a nursing home for a fall requires a skilled lawyer or law firm who understands the state and federal regulations that govern nursing home fall prevention.

Usually, a nursing home fall lawsuit involves a few common steps:

• Investigating the fall: gathering records, witness statements, video footage, etc., to determine what happened and whether there was negligence;
• Investigating the nursing home and parent company: gathering information about this facility and, if appropriate, the parent company, to verify why the fall occurred in the bigger picture–usually understaffing.
• Preparing and filing a nursing home fall lawsuit
• Prosecuting the  claim in court by making them answer written questions (“discovery requests”), having witnesses testify under oath (“deposition”), and trial.

The whole process can take anywhere from 6 months to a couple years or–in rare cases–longer.  Most of that time, you won’t have to be doing anything.  Your lawyers should be, though!

Nursing homes hire experienced lawsuit defense lawyers, and they have lots of money to spend.  But in the end, you have the power to make them be judged by a jury of your peers if you have a valid claim.

The vast majority of nursing home fall lawsuits–really, any lawsuit–resolves before trial by both sides agreeing to settle the case for a certain amount of money (a “settlement”).

We believe your lawyer should be working the case up like it will be tried in court, however.  That’s because if you prepare for trial, you’re much more likely to increase the value of the case.  Lazy lawyering means lower value for a case.

What does a Comprehensive Fall Assessment and Proper Fall Protocol Look Like?

When a fall occurs at a nursing home or rehabilitation facility, there are protocols in place to make sure that the person who fell is examined and injuries are treated accordingly.

Unfortunately, if staff is not trained or the facility is understaffed, these protocols sometimes are not followed. The first step in a nursing home’s fall protocol should be completing a comprehensive assessment of the patient and completing a detailed report of the fall

In the event that they are not followed, the person who fell is at risk to dangerous complications from the fall. It is imperative that you understand the risks to your loved one if protocol is not followed.

The following is an example of a comprehensive assessment and proper protocol that should follow

The Agency for Healthcare Research and Quality outlines the following as proper protocol for a nursing home or care facility when a resident falls:

1. Evaluate and monitor the resident for 72 hours after the fall.
2. Investigate fall circumstances.
3. Record Circumstances, resident outcome and staff response.
4. FAX alert to primary care provider.
5. Implement immediate intervention within first 24 hours.
6. Complete fall assessment.
7. Develop plan of care.
8. Monitor staff compliance and resident response.

They also outline that steps one through three should be implemented in the first twenty-four hours, that steps five through seven should be implemented within one to seven days, and that step eight should be monitored for at least six months.

When notating the fall circumstances, the AHRQ suggests that it is critical to obtain a full written description of all external circumstances at the time of the incident. This includes environmental factors, equipment and staff activity:

• Date
• Day of week
• Time
• Location
• Type of fall
• Likely cause
• Activity at time of fall
• Staff present
• Type of footwear
• Aids in use
• Restraint use
• Side rail use
• Alarm use 

If you believe that a loved one’s fall was not reported or documented, it is important that you discuss this with the proper healthcare provider. Not reporting an incident such as a fall could result in long term complications or serious injury that could lead to death.

Even if a fall was reported and documented, it is possible for injuries to be overlooked because of poor documentation or inaccurate data collection. Managed Health Care Connect points out that issues with understaffing and increasing time and budget constraints has led to less attention to reviews on fall risk assessments and root cause analyses.

MHCC recommends that the investigation begins immediately, at the time of the event while the working staff is still on shift. They believe that this strategy provides the most accurate way to make a comprehensive report on a resident’s fall.

They suggest that in order to reduce the number of falls at a facility requires what they describe as an organized, consistent approach with straightforward reporting of the fall, while involving the resident’s family and an interdisciplinary care team.

By involving both a team of physicians and the resident’s family, it is possible to identify trends, match fall interventions to a resident’s fall risks.

What Tools Can Be Used to Assess and Prevent Nursing Home Falls?

According to the Agency for Healthcare Research and Quality it is important to identify factors that increase a resident’s potential risk of falling. The Morse Scale is a tool that can be used to predict the risk of future falls and use these risk factors for prevention and also to plan the resident’s care.

They recommend that this tool be used with a clinical assessment and a review of medications. Another tool that can be useful is a Mobility Algorithm tool. All of these tools can help care professionals identify risk factors that could prevent a person from falling.

The Morse Scale

The Agency for Healthcare Research and Quality suggest the use of the following test to assess a person’s risk for falling: 

Registerednurse.com also highlights the importance of evaluating a patient or resident’s fall risk. They suggest that every shift nurse needs to be able to assess a resident’s fall risk and that:

“patients who are at risk include patients who have had a fall in the past 3 months, are taking medications that may increase falls such as Benzodiazepines or hypertension medication, or patients that have an unsteady gait.”

If you feel that your loved one is at risk of falling, ask the care facility if they utilize tools such as these to evaluate their potential risks. Have them explain how they assess the risk of falling as well as methods they use to prevent falls.  

It is important to identify all risk factors and speak with a healthcare professional about a plan to prevent your loved one from falling including evaluating which medications they are taking and their ability to move.

Fall Risks Associated with Medication

In addition to this, the Agency for Healthcare and Quality also states that this evaluation should be utilized in regular intervals to fully assess a resident’s risk for falling. It should also be utilized in conjunction with a medication-related risk assessment tool that would be performed by a pharmacist.

After the risk for falling has been assessed, the pharmacist should decide if medications should be changed, discontinued, or a safer alternative be considered. The following is an example of a chart that analyze medication related risks:

Mobility Algorithm

A treating medical provider can also suggest a Mobility Algorithm test be performed. A nurse or nursing assistant can perform this test to determine fall risks in patients who were not primarily admitted to a care facility for mobility related reasons.

TheAgency for Healthcare Research and Quality suggests that the following test be used: 

By utilizing this tool, healthcare professionals can evaluate a person’s ability to move about in order to prevent them from falling. This is another example of a tool that can be used to analyze potential fall risk factors.  

Do you feel that a nursing or care facility has failed to analyze your loved one’s risks for falling? Have they fallen and future risks been ignored? It is very important to evaluate the risks for falling in order to prevent serious injury and even death. Do not hesitate, ask the facility taking care of you or your loved one’s care today. 

Nursing Home Fall Articles

Sources

[i] “Falls in Nursing Homes,” Centers for Disease Control, available at http://www.cdc.gov/homeandrecreationalsafety/falls/nursing.html

[ii] http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

[iii] Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs. Journal of the American Geriatrics Society 1994;42(9):960–4.

[iv] http://www.cdc.gov/homeandrecreationalsafety/falls/nursing.html