prevention

[destiney]

Many problems in this article need to be addressed which has been copied and pasted below. The are concerns that are recognizable regarding the patient, staff and agency. There are some resources as well to set up a method to address the issue and give recommendations.

Due to at copy and paste method the article was unable to paste appropriately. However you can pull it up online at http://www.ChicoEr.com

Chico nursing home fined $100,000

A nursing: home has been

- ordered to pay a $100,O00 in connection

with -the death of an elder resident.

Jason Smith, a spokesman for Evergreen

,> Hedthcare Management.the Department of

Public Health.

The patient who died, 98-year old resident, slipped out of her wheelchair. She was stranggled by a belt that was suppose to keep her in the chair. She was diagnosed with

Alzheimer's, anxiety, depression, weakness and psychosis,

according to state documents.

Often, she would slip down in her wheelchair. Staff

members had to watch her and pull her up when that happened,

the documents said. For a time, a device called a

pummel cushion was used to help keep her in the chair,

but for some reason its use was discontinued. A restraint

called a "soft waist belt" wa3 used to help prevent her

from falling out of the chair.

During supper on Dec. 7, the woman kept sliding

down in her wheelchair. It happened so many times that

two certified nurse assistants (CNAs) who were working

in the dining room decided to put her to bed immediately,

documents stated.

The two CNAs, who weren't regular staff members but

had been hired through a registry to work temporarily,

were taking the woman to her room when they were

stopped by a family member of another resident, who

asked them to put that resident to bed first.

According to documents, the two CNAs said they

thought the woman in the wheelchair would be all right

by herself for a little while, so they left her in the doorway

of her room and attended to the other resident.

Twenty to 30 minutes later, the documents said, the

two CNAs came out into the hall and noticed that the

door was closed to the room of the woman in the wheelchair.

They opened the door and saw the woman on the

floor with the waist belt pressed against her neck and

chest, the documents stated. She wasn't breathing.

The nurse assistants began performing CPR, but a

nurse who had been called told them to stop because the

woman had left instructions that she was not to be resuscitated,

the documents said..

Twin Oaks reported the incident to the Department of

Public Health, which investigated. The nursing home was

issued a Class AA citation for failing to keep the resident

safe and not providing adequate supervision.

Class AA citations are the most serious the state

issues. They carry a fine of between $25,000 and

$loo,ooo.

The nursing home was required to develop what's

called a plan of correction. In its plan, the 'kin Oaks

administration said the entire staff, including employees

hired through registries, would be instructed that residents' safety must take priority over all other concerns.

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[misplaced1]

I have mixed feelings about this. Although, obviously we don't want this happening ever again, who is at fault? The likely overworked CNAs, nursing home? I have been in the postion of running back and forth trying to take care of someone who was a fall risk and already had an injury from one fall. A person like this and the lady in the wheelchair shoul be one on one but that costs a lot of money. Sure it needs to be done but who is going to pay for all the one on ones an who should be making the decisions.

Seems to me like the people that have the power to make the decisions are often not the ones that are in the end held responsbile. At least this nursing home is being hel somewhat responsible by being fined, although I am sure that is little consulation to the patients family. From the little I have seen patient safety is NOT number one as you stated in your maessage. Working with the lest amount of staff that one can get by on is the number one priority of most nursing homes.

Maybe we should rethink this "for profit" thing with regard to nursing homes.