Nursing Home Penalized for Fatal Fall

HarmarVillage entry wayAccording to the Pittsburg Post-Gazette, nursing home resident Delores Cerutti, 83, passed away because of fatal injuries that were a result of a fall in her bathroom at HarmarVillage. The article reports that the Allegheny County Medical Examiner’s office ruled that she died of head injuries from  fall.

It was reported that she had a history of falling. State inspectors ruled in their report that the resident was not properly monitored given her history.

The report noted:

 the death of a resident who was “a high risk for falls due to an unsteady gait, visual disturbances, seizure disorder and bladder dysfunction.” To avoid potential injury, she was supposed to be supervised by someone “in proximity to the bathroom door” when she used the toilet.

The Post-Gazette also reported that the aide responsible for Cerutti told the state inspectors that he was unaware of the resident’s risk factors or an order that would prevent her from utilizing the restroom alone. In order to prevent future falls:

HarmarVillage indicated that all direct care staff would undergo new training related to fall intervention and a new data system would be used to keep employees aware of all residents’ level of fall risk.

Importance of Evaluating Risks of Falls 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.

According to the article, such precautions were in place but the aide was unaware of the risk factors. This patient had an unsteady gait, a history of falling, and was potentially on medications for disorders that could cause her balance to be off.

There should have been several safeguards to prevent her from falling. This includes being aware and upholding orders to keep residents from utilizing the restroom alone if they have a high risk of falling.

It is important for you to ask about these sorts of safe guards for your loved one.  What sorts of risk analysis tools does the facility your loved one is at use? How often do they assess the risks? Do they consider the medication your loved one is on?

Tools for Evaluating Fall Risks

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. It is important to ask about these analysis tools and how they are implemented.

The Pennsylvania Health Department has issued a six month provisional license for HarmarVillage Care Center. This penalty is important because care facilities in Pennsylvania typically operate under a twelve month operating license. This shorter license means that State officials will be watching the facility more closely.

When determining which care facility is right for your loved one, it is important to pay attention to these sorts of penalties as well as monetary ones. For example, this facility is under scrutiny because of numerous problems over the years. It is situations like this that can potentially become dangerous for your loved one.

It is also important to research a parent company if one is present because they may have more than one facility that is in trouble. For example, this facility’s parent company owns eleven facilities and each one had been cited for problems.

You can read the full article here.

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