The Baseline Care Plan and Risk Management in Skilled Nursing Facilities

Several years ago, I overhead my admissions director tell a family over the telephone, “If your mother is falling at home, you can admit her here. She will not fall here.” This, of course is as untrue as “one size fits all” or “the check is in the mail.” Families may have unrealistic expectations about what can or cannot be done to prevent falls in the facilities.

A few years ago, a woman who was 99 years of age, had advanced dementia, and was legally blind, was at home with a 24-hour caregiver when she fell from her bed and fractured her right hip. After a surgical repair, the patient was transferred to a skilled nursing facility (SNF), where a second fall occurred within 48 hours of admission and she fractured her left hip as well. The resident’s son sued the New Jersey nursing home for the injuries his mother sustained.

When he was deposed, the son was asked about his expectations regarding what would happen when his globally confused mother was moved from her home to a hospital to a nursing home, where she knew no one and was unaware of her surroundings. He replied, “I expected they would keep her safe,” although he had no concrete ideas about how that would occur. When confronted with the fact that his mother fell at home even though she had one-on-one care which was not provided at the SNF, he again had no specific answer about why the facility was liable for the right hip fracture, but there was no liability for the left hip fracture sustained at home.

There is an opportunity to mitigate the risk of malpractice claims using the baseline care plan. At the time that the baseline care plan is created, staff can discuss with the family and resident the intrinsic and extrinsic causes of falls identified for that resident.

They can highlight the irreversible factors that contribute to falls such as cataracts, macular degeneration, muscle weakness, joint instability, orthostatic hypotension, strokes, Parkinson disease, neuropathy, and dementing diseases which may alter an individual’s visual-spatial perception as well as their understanding about safety. Frailty, a geriatric syndrome which encompasses weakness, weight loss, sarcopenia, and confusion, is also a major contributing factor to falls. These issues are not within the control of the facility.

The extrinsic causes of falls include the conditions of the building which may pose an increased threat to safety such as slippery shower rooms, loose handrails, glare, insufficient lighting, the lack of proper assistive devices, and improper footwear. These extrinsic issues are under the control of the SNF and can be addressed proactively to minimize the risk of falls.

By discussing what a SNF can do to address falls as well as what is not within the control of a nursing facility, staff can take proactive steps to educate residents and their families and promote realistic expectations about care delivery.