116 Falls in Six Months at Westminster Communities of Bradenton
Westminster Communities of Bradenton has been cited for abuse after multiple residents experienced multiple slip and falls. The facility log revealed 116 falls in a six month period, even though there is space for just 59 residents.
One resident fell shortly after being admitted to the facility, falling so hard that he broke a sink cabinet beyond repair. After waiting for an extended period of time on nursing home staff for assistance, the resident decided to get up and go to the bathroom himself. In this walk the resident fell and hit his head on the sink cabinet in his room.
The resident’s wife shared that he gets anxious without her, so she tries to stay with him as often as possible. She left that day for about 30 minutes to stop by her home, and in that time the resident had fallen.
This resident had already been evaluated as a fall risk and needed help with all activities of daily living, including going to the bathroom. He was known to have impaired physical balance, general weakness, medication that made him prone to falls, disruption from his previous environment, and poor safety awareness. Nursing staff have to prioritize the needs of all residents, but some like this resident need more assistance with daily tasks and require more frequent attention.
A Registered Nurse (RN) Supervisor spoke with the state surveyor about the fall investigated for this citation. The RN looked over his file, saying “He was an accident waiting to happen. He really needed one to one [care].” The RN also shared details of the night before the resident fell and described his agitation and need to get up and down throughout the night, using his foot to kick over his wheelchair while sitting on his bed out of frustration. Because of this, the RN had the resident taken to sit at the nurse’s station so that he could be monitored closely and calmed.
There were “five or six” residents that this RN believed needed close observation. However, the facility only staffs three to four aides at night. This nursing home had evaluated residents as fall risks, and the staff knew who these individuals were, but the facility did not staff enough individuals to care for all residents. Another RN said she tries “positioning someone to
watch the resident as best as they can, but we have other things to do.”
The resident did not fall during the night shift, but this citation reveals the facility’s failure to adequately care for residents. Certified Nursing Assistants (CNAs) are often the ones assigned to help residents complete daily tasks and monitor residents overnight, but this position comes with an immense burden of care and low pay. The average hourly wage for a CNA is $11-$13. Overworked staff only put residents at risk.
Fall prevention is an essential part of nursing home care. When a facility has a clear record of resident falls, it shows a complete disregard for the residents’ quality of life. Dark hallways, slippery floors, footwear prone to slipping, and medication can all increase fall risk. These 116 falls show that the facility was likely not paying attention to dangerous areas or educating its staff on proper fall prevention.
The concern with this nursing home is not only its individual fall incidents, but the pattern of falls. Falls often cause serious injuries to nursing home residents and are a clear reason for nursing home citations. The surveyor interviewed nursing home staff and administrators, but there was no facility plan to address a specific area or time of day in which falls were more common.
It is expected that a nursing home see these patterns and actively work to correct them. Falls are a serious risk to patients in nursing homes. A fall could mean a broken leg that never fully recovers, reducing a resident’s mobility permanently. A fall where a hit to the head is involved could also result in cognitive damage, internal bleeding, or impaired balance. All of these outcomes create more health issues and lower quality of life for residents.
There were so many falls in the short six month review period that the surveyor not only reviewed specific complaints but also sampled the care plans of six residents who had fallen in the observed months. The surveyor noted that the care plans for these residents had similar approaches, even though residents at risk of a fall have very different interventions they need to stay safe.
Review of a resident’s care plan after a fall is an opportunity to improve the quality of care a resident receives, but the survey of six care plans also revealed that the nursing home used repeats of previous approaches already in the care plan. Further in-depth review by the surveyor showed that the nursing home did not include individualized approaches that took into consideration individual needs and preferences. With the resident profiled in the citation, no additional interventions were included in his care plan. This means nursing home staff did not create any new practices to address the resident’s fall risk.
When asked about these falls, the Director of Nursing said that she did not think the facility had a problem with excessive falls. The Corporate Registered Nurse of the facility responded that their quality assurance program to catch errors like an impersonal care plan was “a work in progress.” With more than a hundred falls in a six month period at a facility with space for 59 residents, this response shows a clear disregard for the safety of nursing home residents.
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