“Neglect is cited in nursing home death”—Or Was It Really The Failure Of The System?
There recently was a short article in the Minneapolis Star Tribune in which a nursing home was cited for neglect in a resident’s death. In reading the information contained in the article I think a better, more accurate way to state the problem instead of neglect would have been to cite the nursing home for a breakdown in their resident care system. I see a lack of a systems approach using human factors for resident care. For if one was in place the death of the resident could have been prevented.
Let’s take a look at the article:
“A Red Wing (MN) nursing home neglected a resident in September when the man was placed in the wrong wheelchair, took a tumble and died from complications from the fall, according to an Office of Health Facilities Complaints report made public Wednesday.
The resident of Red Wing Health Care Center had dementia and had a history of trying to get out of his wheelchair, which was fitted with a self-release seat belt and an alarm that sounded when the man stood up.
A worker put the man in his roommate’s wheelchair one morning. Workers heard him fall and found him lying under the wheelchair. He sustained a neck fracture and a head wound and died at the hospital.
The home now places initials on wheelchairs and has told staff to read care plans.”
Reading the article one sees that the details to this incident are very common in long term care settings in general. The details are with my comments underneath:
- Resident who died had dementia
- Many long term care residents are in those places because they have dementia
- Resident had a history of getting out of his wheelchair
- It is pretty common for residents that are physically frail and/or have poor balance who use wheelchairs to want to get out of them
- It is a well-known fact amongst caregivers and administrators that residents are at high risk of injury if they get out and fall
- Caregivers regularly transfer residents into and out of wheelchairs
- It is a task caregivers do frequently each day
The incident happened because the caregiver placed the resident in the wrong wheelchair—his roommate’s. Without knowing more details about incident it is hard to determine if the nursing home neglected the resident after he was placed in the wrong chair. We don’t know the length of time between being placed in the wheelchair, when he got out of it and fell, and when the caregivers found him. If it was several hours I could understand the citing for neglect—this would be true whether he fell out of his own wheelchair, bed or other piece of furniture.
The one thing that jumps out at me which was not stated in the article was the “human error” of the caregiver. The caregiver didn’t notice that s/he placed the resident in the wrong wheelchair. Most likely the caregiver had done this before without incident but this time a mistake was made. My question is why no one ever thought that a mix up could happen? Why wasn’t this process/system evaluated for preventing human error? If it had, there would have been a process within the resident care system to address this.
My grandmother was in a nursing home nearly 20 years ago and everything she owned/used had her name on it. This was true of her wheelchair, clothes, hand mirror, etc. One can assume from the article that this facility did not have this practice or it didn’t apply to the wheelchairs.
The “fix” for the breakdown in the system was also interesting to me. It stated the facility would “place initials on wheelchairs” and tell staff to “read care plans”. Is this an effective solution that will prevent reoccurrence? I’m not too confident. What happens if/when residents have the same initials? What alternate system is in place to account for similarities between names? What about the location, color, size, font, etc. of the initials?
The second part of the solution was for caregivers to read the care plans!?! Really? Is one to assume that before this incident that none of the caregivers ever read the care plans? If so, that is a major flaw of their resident care process. If a caregiver is assigned to a resident it should be “just culture” for that caregiver to know the care plan.
The system in place to care for residents at this facility appears to have many gaps that were not and probably are not apparent to those who work there. It’s part of what I call the “We always done it this way syndrome”. The risk has always been there but no one has looked at the process for deficiencies in regards to work process and resident safety. The question that should be asked is “What other breakdowns are built into the system that is “normal” that could lead to similar resident injury and deaths?”