The Washington Post had a recent article about how falls in the elderly lead to death caused by brain injuries.  This is why it is so critical for nursing homes to have sufficient staff to supervise resdients, prevent falls, and have a fall prevention program.  Below are excerpts of the article.

The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls.

The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.  CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.

"A lot of people don’t think a fall is serious unless they broke a bone, they don’t think it’s serious unless they break a hip. They don’t worry about their head," said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University

Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.   Previous CDC research showed that the U.S. death rate from falling has risen dramatically _ about 55 percent _ for the elderly since the 1990s.

As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.   That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.

The severity of brain injuries isn’t always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.

The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.

There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination _ such as tranquilizers and sleeping pills _ can also make a difference.

"Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either," Wald said.

The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

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The Almanac News had an article about a nursing home appealing a fine after a resident’s death caused by their inattentiveness and lack of supervision.

During her 10-month stay at Atherton Healthcare nursing home in Menlo Park last year, 51-year-old resident Debra Nickel fell 14 times, including a fall where she suffered a traumatic brain injury. She died several days later.  State investigators have determined that the nursing home staff is at fault for Ms. Nickel’s death.  The facility was fined $100,000 for the neglect which is the most severe citation possible.

The Department of Public Health concluded that Atherton Healthcare staff was inattentive in caring for Ms. Nickel, who was known to be at risk for falls. The facility was hit with an "AA" citation the most severe citation under state standards.  "The facility failed to identify and continuously assess, evaluate and update the resident’s needs and plan of care to prevent further falls and injuries," according to the report.

Nana Cocachvili, executive director of Atherton Healthcare, located at 1275 Crane St., said the nursing home is appealing the decision, and that Ms. Nickel’s falls were "unavoidable."

Ms. Nickel died Dec. 1, a week after staff member noticed a "deep lacerated wound" on the patient’s head most probably from an "unwitnessed fall," according to the report. The staff member informed a nursing home physician, who stated that Ms. Nickel "does not need to be sent out for stitches because scalp wounds heal easily," the report says.  The staff member notified a second physician, who recommended Ms. Nickel be taken to the emergency room, where she was admitted three hours later with high blood pressure and a heart rate of 128 beats per minute, the report says.

The San Mateo County Coroner’s Office confirmed Ms. Nickel died Dec. 1 of swelling of the brain and brain hemorrhages caused by blunt trauma.

The citation linked to Ms. Nickel’s death isn’t the only Department of Public Health claim Atherton Healthcare is currently fighting.   In April, the state fined the nursing home $20,000 following an investigation into the Oct. 28 death of a 79-year-old man who fell backwards off a wheelchair lift.

The patient, Menlo Park resident Charles Ladeau, suffered major head trauma when he fell while being lifted into a van, and died shortly after the fall.  The incident exposed the fact that Atherton Healthcare was outsourcing the driving of patients to off-site appointments through a private company without a formal contract, and without "written standards how transportation services should be provided," according to the reports.

Ms. Cocachvili said Atherton Healthcare has appealed that decision too, and she argued the blame should lie on the transportation provider whose employee was supervising the patient when he fell, not the nursing home.   however, the nursing home cannot delegate care to a third party.  The nursing home is the health care provider who is ultimately responsible for the care provided to their residents.

In 2005, the facility changed ownership and was known as Canaan Healthcare. The current owners took over in early 2007 and the name switched to Atherton Healthcare.

Journal of Clinical Nursing has an article about a recent study linking the use of sleeping pills containing benzodiazepines to increase falls in nursing homes.
Older patients taking benzodiazepines were 2.9 times more likely to fall   Obviously, patients who fall suffer severe injuries.   Some older patients have impaired cognitive function or limited functional ability and physical strength stemming from chronic physical ailments, increasing their risk of a fall, often when walking or being moved.

In addition, older patients are take multiple medications, whose side effects increase the patients’ chances of a fall.  Physical restraints may be used to decrease the possibility of falling and being injured.

"Even if no physical injury occurs, fall victims may develop a fear of falling again and thus reduce their activities as a result," the authors wrote. "This can lead to unnecessary dependency, loss of function, decreased socialization, and a poor quality of life."

The researchers found that use of sleeping pills containing benzodiazepines was significantly associated with fractures supporting the findings of most previous studies.

Patients using wheelchairs and bed rails were less likely to fall, but neither of the associations reached statistical significance. Nevertheless, "the use of these might be regarded as protective or preventative strategies," the researchers said.

Bed rails can cause injuries if patients climb over them, and physically restraining an already agitated individual can increase fear and worsen behavior, they said.   "In addition, restraints can lead to serious complications, including circulatory obstruction, skin tears, incontinence, fractures, and dislocations," they wrote. "These restraints should be used with care and consideration." 

The Study recognized that restraints cannot completely eliminate falls in nursing homes and that they may not be appropriate in every situation, but concluded that "our results support the hypothesis that they might be protective when used selectively together with fewer sedatives, especially benzodiazepines."

Primary source: Journal of Clinical Nursing
Source reference:
Fonad E, et al "Falls and fall risk among nursing home residents"J Clin Nurs 2008; 17: 126-134.

Here is another article about a nursing home’s failure to prevent a resident from falling and then failing to intervene or inform the family. 

The family was never told that their 60-year-old mother had broken both legs in a fall and died of complications.  Eventually,  the family discovered the horrific details. Their mother, Linda Ober, had been dropped by staff at the nursing home where she lived and left to moan for help in her bed for five days.

Employees tried to cover up the injury by giving her pain medication and telling her that her memory of being dropped as they moved her out of her wheelchair was simply a bad dream.  The family is haunted by the thought that her mother spent her final hours wondering why her daughter didn’t come to see her. According to the suit, the resident  told hospital staff that they didn’t need to call her daughter, because nursing-home employees said they would. Cunningham, who lives a mile from the nursing home, said she was not told.

"I wasn’t there to hold her hand," said Cunningham, breaking into tears. "All I needed was a phone call."

Thomas D’Amore, the attorney representing Cunningham and her siblings, said Ober’s death was the result of having too few staff and not adequately training them to care for the center’s residents. According to the U.S. Department of Health and Human Services, a review of the Gateway nursing home about the time of Ober’s death found that the number of nurse-hours per resident was below the state average by 33 percent.

She was critically injured Oct. 29, 2006, when two employees dropped her after improperly wrapping a sling around her torso to move her from her wheelchair to her bed, according to the suit.   X-rays show Ober’s badly broken legs. In one X-ray, her femur is jutting away from its normal position by 45 degrees. According to a summary of a state investigation that D’Amore provided, staff who treated Ober at Mount Hood Medical Center said Ober’s pain was "off the scale" and that "you could feel the bones in her legs moving in your hands, and they were crunching."

I read an article today about the death of a resident caused by the improper transfer by the nursing home staff.  Falls are always so dificult for the elderly to survive.  the injuries cause by falls can lead to immobility, pain, and demntia.  Preventing falls should be a high priority but often isn’t.  Training and staffing are lacking in this area.

A Pennsylvania Coroner concluded a nursing home resident’s death was caused by injuries she suffered after being dropped by staff from a mechanical lift.    Judith Bilger was dropped Aug. 9 and died three days later at the Laurel Crest Rehabilitation & Special Care Center.

Coroner Dennis Kwiatkowski says the 64-year-old woman died from internal injuries caused in the fall.   Among other things, she broke ribs and developed pneumonia from a lung contusion.

Proper staffing and education on proper use of mechanical lifts could have prevented the above incident and prevented this woman’s death.

Violations of "accident hazards" were the most frequently cited survey flaw across the nation in September, according to the Centers for Medicare & Medicaid Services. These hazards typically cause falls and injuries to occur.  The agency said 35.2% of the facilities cited were written up for F-tag 323.

Next on the list was a frequent No. 1 entry in the Top Ten list: F-tag 371 ("store, prepare, distribute and serve food") at 33.9%. This is very disturbing considering the importance of dietary and nutritional aspects for maintaining and improving the health of elderly residents especially to prevent or heal pressure ulcers.

Filling out the top five were: F-309 (each resident must receive care for highest well-being) at 27.7%; F-281 (services must meet professional standards of quality) at 26.9%; and F-279 (Facility must develop comprehensive care plan with objectives/timetables.  

All information was culled from CMS’ Online Survey, Certification and Reporting (OSCAR) data.

 A wrongful death lawsuit was filed against a Menomonee Falls nursing home, contending that a resident died from complications caused by broken bones in both legs that she suffered during a fall that was not reported.

Dorismae Burgardt was dropped by a nursing assistant at Menomonee Falls Health Care Center using an improper technique. The incident was not reported to a registered nurse or the woman’s physician. The first mention that something was amiss came the next day, when it was noted on her chart that Burgardt had "bruises" on both knees caused by being "lowered to the floor".

Three weeks later, Burgardt was dead. She was 81.

"This lawsuit is about dignity and safety," said attorney Jay Urban, who filed the lawsuit on behalf of Burgardt’s estate and her husband, Allan Burgardt of Germantown. 

See full article

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Hip Fractures Among Older Adults

More than 95% of hip fractures among adults ages 65 and older are caused by falls (Grisso et al. 1991). These injuries can cause severe health problems and lead to reduced quality of life and premature death (Wolinsky et al. 1997; Hall et al. 2000).

How big is the problem?

In 2003, there were more than 309,500 hospital admissions for hip fractures (NCHS 2006).
From 1993 to 2003, the number of hip fracture hospitalizations increased 19%, from 261,000 to 309,500 (NCHS 2006).
However, after adjusting for the increasing age of the U.S. population (U.S. Census Bureau 2006), the hip fracture rate decreased 14%, from 901 per 100,000 population in 1993 to 776 per 100,000 population in 2003 (NCHS 2006).
In 1990, researchers estimated that the number of hip fractures would exceed 500,000 by the year 2040 (Cummings et al. 1990).

What outcomes are linked to hip fractures?

As many as 20% of hip fracture patients die within a year of their injury (Leibson et al. 2002).
Most patients with hip fractures are hospitalized for about one week (Popovic 2001).
Up to 25% of adults who lived independently before their hip fracture have to stay in a nursing home for at least a year after their injury (Magaziner et al. 2000).
In 1991, Medicare costs for hip fractures were estimated to be $2.9 billion (CDC 1996).

 

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Falls in Nursing Homes

How big is the problem?

In 2003, 1.5 million people 65 and older lived in nursing homes (National Center for Health Statistics 2005). If current rates continue, by 2030 this number will rise to about 3 million (Sahyoun et al. 2002).
Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported (Rubenstein 1997).
As many as 3 out of 4 people in nursing homes fall each year (Rubenstein et al. 1994). That’s twice the rate of falls for older adults living in the community.
Patients often fall more than once. The average is 2.6 falls per person per year (Rubenstein et al. 1990).
About 35% of fall injuries occur among residents who cannot walk (Thapa et al. 1996).
About 5% of adults 65 and older live in nursing homes. But people in nursing homes account for about 20% of deaths from falls in this age group (Rubenstein 1997).

How serious are these falls?

About 1,800 people living in U.S. nursing homes die each year from falls (Rubenstein et al. 1988).
About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures (Rubenstein et al. 1988).
Falls can make it hard for a person to get around, cause disability, and reduce quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation (Rubenstein et al. 1994).

Why do falls occur more often in nursing homes?

Falling can be a sign of other health problems. People in nursing homes are generally more frail than older adults living in the community. They tend to be older, have more chronic illnesses, and have difficulty walking. They also tend to have problems with thinking or memory, to have difficulty with activities of daily living, and to need help getting around or taking care of themselves (Bedsine et al. 1996). All of these factors are linked to falling (Ejaz et al. 1994).

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