Falls

Case Types

Not all falls are preventable, but many are. A nursing home must use all available measures to prevent falls. If a fall is preventable, and a nursing home fails to take the appropriate steps to prevent it, that is considered abuse and neglect.

Are Falls at Nursing Homes a Sign of Abuse and Neglect?

Preventing falls always includes three steps. First, the nursing home must perform a comprehensive assessment to identify each resident’s risk of falling. Second, based on that assessment, the nursing home must create a care plan that identifies specific measures to prevent the resident from falling, such as alarms and increased supervision. Third, the nursing home must actually implement the plan that has been created.

If the nursing home fails to carry out any of these steps and a resident is injured, that is considered negligence.

How Common are Falls at Nursing Homes?

Falls are common in nursing homes. There are approximately 1.6 million residents in nursing homes in the United States. Half of those residents fall every year. That means that 800,000 nursing home residents fall each year.

Approximately 1 of 3 residents who fall will fall at least two more times during the year. Many of these falls are preventable with reasonable care.
On average, a nursing home with 100 residents reports between 100 and 200 falls yearly. Many more falls go unreported, making the number much higher.

Are Falls at Nursing Homes Deadly?

The elderly are fragile. Falls often have serious and even deadly consequences, especially in frail nursing home residents. One in every 10 residents who fall has a serious injury. Around 65,000 patients suffer a hip fracture each year in a fall. Hip fractures are one of the most feared injuries in nursing homes. It is estimated that as many as 58% of residents who suffer a broken hip at a nursing home die within the year.

The most common injuries we see that result in lawsuits for falls are:

Subdural hematoma (brain bleed)
Traumatic brain injury
Fractured hip and femur
Fractured spine, especially at the neck
Fractured collarbone
Fractured pelvis

Even when residents who fall do not die from their injuries, fall-related injuries decrease the resident’s quality of life. Residents who fall often develop a fear of falling that leads to self-imposed restrictions on activity, causing the resident to become deconditioned and at an increased risk of falling again.

Residents who are not seriously injured in a fall often suffer:

Reduced quality of life
Increased fear of falling and restrictions of activities
Decreased ability to function

Each of these changes increases the risk of falling again, putting the resident at risk of serious injury or death.

What Are the Most Common Fall Risks?

Falls among nursing home residents are usually the consequence of a combination of risk factors. Some risk factors are considered intrinsic, meaning they are specific to the individual resident. Other risk factors are considered extrinsic, meaning they are part of the external environment.

Intrinsic Risk Factors

Intrinsic risk factors include:

Effects of aging on balance, strength, and the ability to walk
Acute medical conditions, like infection, dehydration, or delirium
Chronic diseases, like diabetes, heart disease, orthostatic hypotension (lightheadedness or fainting when standing), arthritis, or problems with nerves, feet, thyroid, or blood vessels that can affect balance, or the long-term effects of a stroke
Deconditioning from inactivity, potentially long-term deconditioning or after a hospital stay
Behavioral symptoms from dementia or other condition that decreases safety awareness
Medication side effects

Although intrinsic risk factors such as underlying medical conditions cannot be eliminated, they can be managed in a way that reduces the resident’s risk of falling. Medical management conditions can be improved through appropriate evaluation and treatment.

Extrinsic Risk Factors

Extrinsic risk (environmental) factors can also be addressed to improve safety. Extrinsic risk factors include:

Poorly fitting wheelchairs
Bad lighting
Cluttered living space
Uneven floors
Wet areas
Unstable furniture
Unstable bed wheels
Ineffective wheelchair brakes
Missing equipment parts
Improper footwear
Hard-to-manage clothing
Inaccessible personal items, like glasses or remote control

Are Falls at Nursing Homes Preventable?

Most falls at nursing homes are preventable. While there may be rare instances where no one could foresee a resident falling, in the vast majority of cases, the resident has demonstrated a risk for falling.

All preventable falls are caused by some combination of (1) a failure to perform a comprehensive fall risk assessment, (2) a failure to create an appropriate care plan that includes fall prevention measures, and/or (3) failing to implement the measures on the care plan.

Fall Risk Assessment

Preventing falls always begins with a fall risk assessment. A fall risk assessment is necessary to both determine whether a resident is at risk for falling and why a resident is at risk for falling.

At a minimum, a fall risk assessment should include an evaluation of whether the resident has any of the following:

History of falls
Impaired cognition, including fluctuating mental status or change in cognition
Impulsivity
Impaired vision or change in vision
Difficulty walking (called a gait disturbance, like shuffling feet or leaning to one side when walking)
Limitations or changes in activities of daily living, including the ability to walk, transfer from a bed or chair to a wheelchair and on and off toilets, and bed mobility)
Use of assistive devices for walking or getting in and out of bed or off toilets (like a cane, walker, or restraints)
Bowel and bladder incontinence
Infection
Underlying medical conditions affecting balance, endurance, strength, judgment,or vision
Use of high-risk medications (for example, opioids, antihypertensives, psychotropics, sedatives, diuretics, or hypoglycemic agents)
The use of multiple medications (polypharmacy)
Equipment attached the resident (for example, catheters, IV lines, or oxygen)
Environmental conditions (for example, clutter, poor lighting, or glare)
Familiarity with the environment (including room change or new admission)
Recent hospitalization or change in condition

These fall risk factors are considered cumulative. The more of these risk factors a resident has, the higher the risk of falling.

A fall risk assessment should be conducted upon admission to the facility. It should also be conducted anytime the resident is hospitalized and reenters the nursing home. The best practice is to perform a fall risk assessment every month–although this is rarely done in nursing homes.

Fall Interventions

There are dozens upon dozens of potential fall interventions. Every risk factor identified in a fall risk assessment should be addressed by at least one fall intervention.

Fall interventions available to nursing homes include:

Behavior management strategies
Monitoring and reporting changes in anxiety, sleep patterns, behavior, and mood
Increasing assistance and surveillance
Frequent toileting to prevent patients from attempting to get up on their own
Low blood pressure precautions
Removing or reducing medications that decrease alertness or cause dizziness
Increasing staff assistance with toileting, transfers, and other movement
Motion detecting cameras
Movement sensors
Pressure sensing bed and chair alarms
Tilt-in-space wheelchairs or broda chairs to prevent the resident from fall forward out of a chair
Promoting wheelchair safety
Nonskid surface to the wheelchair seat to prevent slipping
Physical and occupational therapy
Exercise programs to increase balance and strength
Bed in lowest position
Low bed (this is different than a bed in lowest position and actually sits directly on the floor)
Bolsters around the perimeter of the mattress to prevent falling
Nonslip mat
Nonskld strip or nonskid rug
Nonskid socks
Soft floor mats to lessen injury of a fall occurs
Helmets, wrist guards, or hip protectors to lessen injury of a fall occurs
Increasing bed or chair comfort to deter attempts to stand
Low vision precautions
Keeping all personal items in reach
Educating nursing staff to identify fall risk behavior

For every fall risk, there are numerous potential interventions. Nursing homes must be proactive in identifying fall risk factors and implement remedial measures. If an intervention does not work, then the nursing home must immediately add new interventions to prevent falling.

Implementing the Care Plan

It is not enough to assess a resident and identify fall interventions. Nursing staff must carry out the plan of action. Nursing homes are often neglectful in this aspect of care.

Improperly Responding to Falls at Nursing Homes

Nursing homes must train their staff to respond appropriately when a patient falls. Many lawsuits are brought because nursing staff fail to respond to a fall increasing the harm to the resident. There are several standard responses to a fall that must be met, but often are not.

Many falls are unwitnessed because they happen in a patient’s room or because the facility is short staffed and there is no one around to see it. If a fall is unwitnessed, nursing staff should assume the worst. They should approach the patient with the expectation that the patient fell from a standing height and suffered a serious injury.

Only a registered nurse is permitted to assess and evaluate a resident after a fall. Because of budgeting to increase profits, many nursing homes are woefully short on registered nurses and use almost exclusively licensed practical nurses. Licensed practical nurses are exactly that, “practical nurses.” They have less education and training than registered nurses and are permitted to carry out or practice at the direction and under the supervision of registered nurses. While only a registered nurse can assess a patient, because of a lack of resources provided to the facility by corporate ownership, licensed practical nurses are left to carry out this critical function.

If there is any sign of injury or suspected injury, including if the fall is unwitnessed, the resident should remain on the ground during the assessment. Sudden movement can cause severe pain if there is a fracture. In addition to causing pain, if there is a fracture, moving the patient can cause the bones to move or displace. This makes the fracture more difficult to heal and can result in surgery that otherwise would not have been needed.

If the patient has any signs of trauma above the collarbone, the nursing home should immediately send them to the hospital. Elderly people, and the vast majority of nursing home residents are considered elderly, are at an increased risk of suffering a brain bleed when they fall. As part of the natural aging process, our brains shrink. Because our brains shrink, there is more room in the skull for our brains to be jostled and injured in a fall. The most common injury that occurs is a subdural hematoma. This occurs when blood vessels in part of the lining of the brain tear and bleed into a space between the brain and the skull. Because our skulls are a fixed box and cannot expand as blood increases (like our skin can if there is a bruise or hematoma under it), as bleeding increases pressure is placed directly on the skull. This pressure can be relieved with a relatively basic procedure where part of the skull is temporarily removed and the blood is drained. There is a limited amount of time to do this, however. If the resident does not get immediate medical attention, the result is often permanent injury or death.

Nursing home’s are required to notify a physician if a resident has a significant change in condition. A fall with an injury, or even no injury, is always considered a change in condition worthy of notifying a physician. Because they are not doctor’s, nurses do not have the right or authority to diagnose the patient as suffering an injury or not.

Under federal and state laws, residents have a right to participate in their own care. Most nursing home residents have either a guardian or a medical power of attorney. These people stand as a proxy in the shoes of the resident to make medical decisions. Any time a resident has a change in condition, including a fall, the nursing home must provide the resident with detailed information concerning what happened, how it happened, and what is being done for the resident. This information must also be provided to the resident’s guardian or power of attorney.

A nursing home’s failure to properly respond to a fall is considered abuse and neglect and may form the basis of a lawsuit.

Representative Cases

Lou

Lou was a 70-year-old man who entered a nursing home outside of Cleveland, Ohio to recover from brain surgery after an aneurysm. While at the nursing facility for rehab, he fell 5 times. He struck his head in the fifth fall. He developed a subdural hematoma, which is bleeding between the skull and the brain. The nursing home delayed sending Lou to the hospital for several hours. During that time, the blood continued to pool in his skull putting increased pressure on the brain. By the time Lou was taken to the hospital, it was too late. He suffered permanent brain injury and died. A Cuyahoga County, Ohio jury returned a verdict of $5,000,000.

Marianne

Marianne entered a nursing home outside of Warren, Ohio after she had elective back surgery. She went to a nursing home for rehabilitation before returning home to live with her husband. At the nursing home, she fell suffering a burst fracture to her newly repaired spine. Over the following days, she began to lose feeling in her legs and had difficulty controlling the placement of her feet. The nursing home delayed calling her surgeon for several days. When she did finally see her surgeon, it was too late. She had lost bowel and bladder function and could no longer walk. The case settled for $1,950,000.

David

David was a resident of a group home in northeastern Ohio. He was 60 years old and had a history of Down syndrome. David had begun demonstrating instances where he was falling to the floor when staff attempted to move him. Staff then noticed that he was having difficulty using utensils and was sleepier than usual. David was taken to the hospital where it was revealed that he had suffered a subdural hematoma, which is a brain bleed, several days before. Surgery was performed to remove the hematoma. The case settled for $700,000.

Myrtle

Myrtle was a 78-year-old resident of an Akron, Ohio nursing home. She had severe dementia that was characterized by anxiety, agitation, and outbursts. She was also known to be a very sweet and funny woman. She had an unwitnessed fall in the hallway. She was only discovered after staff heard a loud thud in the hall. She died as a result of complications of the broken femur and shoulder she suffered in the fall. The case settled for $600,000.

Leona

Leona was a 76-year-old woman who lived in a nursing home outside of Cleveland, Ohio. She had suffered a stroke years earlier and needed around the clock care. She required two people to assist her when moving in bed. Because of short staffing, one nursing home resident attempted to move her in bed. Instead of rolling her in bed, the staff member rolled her off the other side of the bed. Leona fractured her hip in the fall. Over the next several weeks she declined until she died. The Cuyahoga County Medical Examiner determined that she died as a result of the injuries in the fall. A jury in Cuyahoga County, Ohio returned a verdict of $4,400,000.

Lydia

Lydia was a 94-year-old resident of an assisted living facility outside of Cleveland, Ohio. She fell numerous times and was known to be a high fall risk. The facility created an inadequate care plan that did not address her needs and then failed to actually follow the substandard care plan they had in place. One night, an aide entered her room and had Lydia use a walker to go to the restroom. The aide trailed her pushing a wheelchair. The wheelchair struck Lydia’s left foot causing her to fall to the ground and break her femur. Lydia died several days later. The case settled for $1,250,000.

Gene

Gene was a resident of a nursing home outside of Akron, Ohio. Gene had dementia and often wandered the facility alone. Although Gene had no fallen previously, he did have signs that he was at risk of falling and needed additional physical therapy and exercise programs to improve his strength and balance. Those were never provided. Gene fell while wandering the hallway unsupervised one night. He suffered a broken hip in the fall. He was taken to the hospital where the hip was surgically pinned but he died from complications of the surgery. The Summit County Medical Examiner determined that Gene died from complications of the broken hip. The case settled for $650,000.

Mercedes

Mercedes was a 97-year-old resident of an assisted living facility in Wadsworth, Ohio. Mercedes fell from her bed striking her head. She had a large bump on her head. She was not sent to the hospital until her family saw her three days after the fall, and she was slurring her words and drowsy. Her family demanded that she be sent to the hospital. At the hospital, she was diagnosed with a subdural hematoma. Miraculously, she recovered enough to go to a nursing home for rehabilitation. At the nursing home, an almost identical series of events occurred. She fell and hit her head. Her family was not told for three days. When her family visited, she was slurring her words and lethargic. She was sent to the hospital where she was diagnosed with a larger subdural hematoma. The lawsuit is scheduled for trial in Medina County, Ohio.

How Much is My Nursing Home Fall Case Worth?

Every case is unique and has to be evaluated on its specific facts. The only way to determine the value of your nursing home fall case is to begin an investigation.