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.
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
