Tuesday, November 25, 2008

Wheelchair Bound Resident Falls Down Stairs at Washington Heights Nursing Home

1010 W. 95th St. in Chicago
FINED- 2003

Washington Heights Nursing Home was fined $10,000 for
failure to provide adequate supervision to prevent
injury to a resident.
Responding to complaints, Department surveyors
learned a resident sustained scrapes, bruises and
severe swelling to her face and scalp after falling
down a flight of stairs while in a wheelchair.
Despite obvious signs of trauma, staff put the
resident in the wheelchair and carried her back to her
room without stabilizing or assessing for injuries.
Staff did not hear an alarm sound in the stairwell
and the door alarm panel at the nurse's station was
turned off at the time off the incident. During the
Department's investigation, a surveyor found the door
alarm working, but the sound was almost inaudible.
Interviews with employees revealed there was
insufficient staff supervising the area at the time of
the incident. One employee stated she was not
supervising the area because she thought another
employee, who was at dinner, was doing it. In fact,
three of the four nurse aides on the floor went to
dinner at approximately the same time. Another nurse,
who was working on the floor because an employee had
called in, was summoned to work on a different floor
and left without notifying the nurse in charge.
The Department-ordered plan of correction required
the facility to take the necessary precautions to
ensure the residents' environment is free of accident
hazards; to educate all staff in their role of
providing care to and monitoring of residents; and to
document any change in a resident's behavior.

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