KEOSAUQUA — A Keosauqua nursing home face more than $15,000 in fines after the Iowa Department of Inspections and Appeals found it failed to adequately care for residents, including one who fell more than 50 times since January 2012.
The fines are shown in a citation that details events that led to a patient's death in June. The patient, whose name is not given in the citation, had both short- and long-term memory problems and could not safely walk unassisted.
Some nursing homes use a fall risk analysis in which a score of 12 or above indicates a high risk for falls. In December 2012, the resident scored 19. By April of this year, the same analysis gave the resident a score of 25.
From Jan. 12, 2012, to Dec. 19, 2012, records showed the resident fell 36 times, mostly in the afternoon and evening hours. Another 19 falls in 2013 are indicated in the report. Investigators concluded the facility attempted to address environmental issues related to the falls “but did not look at engaging the resident in activities to avoid the wandering behaviors.”
Family members had concerns. They acknowledged the resident would ignore instructions not to walk unassisted and “impulsiveness.” But investigators said the family told them repeated discussions with the nursing home failed to ensure they helped the patient walk or intervene when they discovered the resident doing so.
On June 17, the resident fell in the hallway and was unresponsive when staff got there. There were signs of a concussion, and the resident was taken to the hospital by ambulance. On June 21, the resident died of a subdural hematoma, bleeding between the brain and the skull, caused by the fall.
Staffing appears to be part of the issue, according to the investigators' report. According to a nursing assistant on duty the when patient fell, there were “not enough staff on the evening shift to care for all the residents” and provide the resident who fell with walking assistance.