80-Year-Old Woman Dies After Multiple Falls at Nursing Home; Son Lobbies Governor & Lawmakers

A man whose mother died after several falls at a nursing home has decided to sue after failing to convince the governor, numerous lawmakers, and state health regulators to resolve his complaints.

The 80-year-old woman was first hospitalized after a fall from her bed at the nursing home in January 2008. Over the next two months she suffered at least one more fall at the nursing home, which at the time was operating under an unpublicized consent order from the state department of public health. Officials had reprimanded and fined the 166-bed nursing home $25,000 and put its license on probation for two years.

The original order, which was based “on findings which seriously jeopardized the health, safety, and welfare of patients and which have resulted in serious negative patient outcomes,” would have prohibited the home from admitting new residents. But, in a revised order the nursing home was required to hire an independent physician as a medical consultant, who in turn was to hire an independent nurse consultant. It also set minimum staff ratios for the facility and required the home to ensure compliance with various quality measures, including “necessary supervision and assistance devices to prevent accidents.”

In her final fall, the patient broke her left hip in March 2008 and died three days later at the hospital. On her death certificate, a physician, who was also an assistant state medical examiner, listed the fracture as an “underlying cause.”

The patient's son had complained to the state health department about his mother’s care both before and after her initial fall. The day after her death, he again complained to the agency’s investigations division. He charged that nursing home staff had, against the orders of his mother’s doctor, removed a bed alarm, a personal alarm, and a walker from her room. The health department subsequently dispatched an inspector to the nursing home and in visits conducted over five days last April discovered 11 violations, state records show.

The violations included failures to “provide interventions to prevent falls after the removal of an alarm” and to “utilize an alarm mechanism in accordance with the physician’s order and/or to provide an environment free from accidents.”

What happened after his mother's death is not simply the story of a grieving son bent on blaming a nursing home for not protecting his mother. It also is the tale of an exceptionally motivated man who says he’s determined to prevent similar deaths but has been increasingly frustrated by government bureaucracy and politicians he says have done little more than express their sympathy. He states that his pending lawsuit against the nursing home stems from his belief that it insulted his mother’s dignity by denying her cause of death.

But the son also has pressed his complaints repeatedly upon an extraordinary number of government officials, including his United States senator, his United States representative, the state's governor and attorney general, two state senators, a state representative, and a bevy of state health department officials.

The son has aimed his harshest criticism at the health officials, whom he charges with being “more concerned about the well-being of nursing homes than the residents they should be protecting.” Department of Public Health officials, he says, have been “talking in circles and avoiding the facts” spelled out on his mother’s death certificate, which he insists shows that she died because of a fall. For more information on this son's crusade to prevent nursing home neglect, please read the article.

The nursing home clearly violated existing doctor's orders, according to the report. Fall alarms were discontinued against those orders. Of course, devices and other equipment like personal fall alarms can help monitor a patient’s activities, but do not eliminate the need for adequate supervision. Adequate supervision must be based on the individual patient’s needs and the hazards of the patient’s environment. A nursing home or assisted living facility has the responsibility to ensure the safest environment possible for its patient. Specifically, a nursing home or assisted living facility must provide an environment free from accidents and hazards over which the nursing home or assisted living facility has control and provide proper supervision and assistive devices to prevent avoidable accidents, including falls.

It is encouraging to see the news media reporting so thoroughly on this incident and the lengths the surviving son is going to improve safety at the nursing home. What is not so encouraging is the "brick wall" he apparently is hitting with everyone from the state health department on up to the governor. 

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Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia 



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