Nursing Home Resident Falls Within 24 Hours of Admission, Not Treated, Dies

A nursing home will be fined after a resident fell within 24 hours of being admitted and later died from untreated injuries from the fall.

The nursing home has a history of problems and fines by the state inspection authorities.

In this incident, the resident was admitted to the facility about noon. The resident and spouse both indicated the resident had a recent history of falls. A care plan identified the problem and listed interventions that included a bed alarm and a body alarm.

At 9 p.m. that night, one of the resident's alarms sounded as the resident attempted to get out of bed.

At 4:25 a.m. the following morning, an alarm sounded again. The resident was found on the floor, which was wet with urine, when staff members responded. The first staff member to arrive said in an interview later that the resident fell head first. She failed to tell the nurse that the resident had hit their head.

Staff members did bandage a small wound on the back of the resident's hand. Another staff member did an assessment of the resident's mobility and asked whether the resident was hurt and about what happened. The resident responded "no" to the question about being hurt.

The staff member could not recall for sure if she asked if the resident hit their head. She did not check the resident's pupils or perform any neurological checks.

The resident, the staff member reported, seemed to be doing all right, and was talking with another resident. The resident received morning medications, breakfast and went to the restroom.

At 9:20 a.m., the resident complained of hip pain. Staff gave the resident a pain medication. No assessment was done at the time.

At 10 a.m., family members noted that the resident "became restless and agitated, looking for cigarettes. The resident complained of having a headache above his/her right eye." Upon returning to the room, the resident was unresponsive. The resident was taken to the emergency room.

In a later interview, the resident's physician said the facility did not inform him about the fall. "The physician stated staff frequently contacts him for things much less severe than a fall. The physician added that he would have expected a telephone call at the time of the fall, 4:30 a.m."

However, the doctor said it was "likely the resident could not have been saved if they were notified at the time of the fall. However, but not notifying the physician, the physicians did not even have an opportunity to try." For more, read the story.


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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