“When planning for a year, plant corn. When planning for a decade, plant trees. When planning for life, train and educate people.” – Chinese Proverb
At employee at St. Anthony Health Care Center in St. Paul, MN failed to follow these words of wisdom when she failed to follow the fall precautions set for in a patients care plan. An investigation into the matter, revealed that the nursing home employee’s errors contributed to the patient’s death.
- Failing to activate a fall alarm
- Failing to lower the patient’s bed to a lower height
- Failing to put a mat beside the patient’s bed to provide padding in cases of falls
The patient fell out of her bed and hit her forehead and sustained a subdural hematoma. The patient died four days after the incident.
When questioned by Department of Health investigators, the CNA ‘admitted she used poor judgment’. Incidentally, the investigation revealed the facility itself was not at fault.
I certainly appreciate this CNA’s honesty when it comes to the careless errors she made. However, I am always frustrated when Heath Department investigators fail to impute responsibility on the part of the facility itself. I find it hard to believe no other employees witnessed this situation. Further, it only would have taken another co-worker a few seconds to implement some of the fall precautions had they chosen to check on this patient.
Read more about this case involving neglect in a Minnesota Nursing Home here.