On June 13, 2009, a nursing home patient fell out of bed and died at Fejervary Health Care Center in Davenport, Iowa. This fall occurred within 24 hours of the resident being admitted to the nursing home.
This was not an isolated event at Fejervary. Fejervary Health Care Center has a history of safety problems and has been fined several times by the Iowa Department of Inspections and Appeals.
Last year, the nursing home was fined $7,500 for failing to ensure that each resident received adequate supervision to ensure against hazards from self, others, or environmental elements, and allowing a resident who was an elopement risk to elope from the facility.
According to the government’s Medicare website, the facility received one out of five stars, which is a much below average rating. In the past year, the nursing home had sixteen health deficiencies, which is eight more than the average number of health deficiencies in both Iowa and in the United States. Also, the number of health deficiencies in the past year is twice the number of deficiencies in the previous year.
Following the June 13th fall and death of the resident, the Iowa Department of Inspections and Appeals conducted a complaint inspection on June 29, resulting in a $6,000 fine. The inspection concluded that the nursing home facility failed to provide accurate assessments and timely intervention for a resident who experienced a fall and had a change in condition.
The resident was admitted to the nursing home on June 12 at 12:10 pm. During the initial interview with nursing home staff, both the resident and the resident’s spouse informed the staff that the resident had a recent history of falls at home. Nursing home staff established an individual care plan to help prevent falls. The plan included reminding the resident to use the call light, a bed alarm, and a body alarm. At 9:00 pm that night, the resident’s alarm sounded as the resident tried to get out of bed unassisted.
Then, in the early hours of June 13th, an alarm was sounded and nursing home staff found the resident on the floor, wet with urine. The staff member who responded noted a skin tear on the back of the resident’s hand. After applying a dressing to the resident’s hand, the resident was helped back into bed and was under constant supervision for the rest of the shift.
In an interview with the Iowa Department of Inspections and Appeals, nursing home staff reported that the resident had fallen head first and hit their head. However, the staff member did not tell the nurse that the resident had hit their head. The staff members asked the resident whether the resident was hurt and checked mobility. The staff did not check the resident’s pupils or perform neurological checks and could not remember whether the resident had been asked about whether the resident had hit their head. Staff members did check the resident’s vitals, but only at the time of the fall.
Following the fall, the nursing home staff failed to inform the resident’s physician that the resident had suffered from a fall, even though the staff frequently contacted him for issues much less severe than a fall.
The staff reported that the resident seemed fine going about the day’s activities (eating breakfast, taking medication, talking with other residents, and using the restroom). Later that morning, the resident complained of hip pain and was given pain medication without an assessment. Shortly thereafter, the resident’s family members noted that the resident became agitated and complained of a headache. The resident then became unresponsive and was taken to the emergency room.
The doctor stated that the resident might not have been able to be saved even if the resident’s physician had been contacted at the time of the fall; however, the physician did not even have a chance to try to save the resident’s life since he was not contacted.
The nursing home had an obligation to report any change in condition to the resident’s physician in order to help prevent further injury and even death as was the case here. In addition, the nursing home staff is responsible for providing accurate assessments of resident health, especially after a fall so proper care and treatment can be provided.
Medicare – Fejervary Health Care Center