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QUESTION:

Describe in detail each act or omission on the part of any party to this lawsuit that you contend constituted negligence that was a contributing legal cause of the incidents in question, and describe in detail what you contend Defendant should have done to prevent the incidents.

OUR ANSWER:


Plaintiff was 85 years old at the time she was admitted to Defendant’s facility. Her admitting diagnoses included impaired cognition, general muscle weakness, hallucinations, anxiety, hypertension and chronic kidney disease. According to Defendant’s Quarterly Resident Data Set dated January 7, 2009, Plaintiff required “1 person physical assist” with toileting. The nurse’s notes documented that she also required “1 person assist” with all of her activities of daily living. Defendant’s fall risk assessment found Plaintiff to be at risk of falling. The nurse’s notes repeatedly documented that Plaintiff was alert but had periods of confusion. Additionally, her care plans documented her diminished safety awareness. Further, the Plaintiff was referred to physical therapy due to her “decreased gait skills, decreased balance and weakness.” Thus, the Plaintiff’s fall risk and need for the staff’s assistance with her activities of daily living was well documented and well known to Defendant’s staff.

Although the staff did care plan Plaintiff’s fall risk, they failed to develop sufficient interventions that adequately addressed her fall risk prior to her August 6, 2009 fall, and the minimal interventions that were developed were not consistently implemented, her well documented fall risk notwithstanding. For example, the care plan interventions included: (1) keep the call light in reach (however, Plaintiff initially had no call light at all, and when one was installed, staff usually failed to timely respond to the call light, if at all); (2) remind the resident to call for assistance (however, per the nurse’s notes, this was not done until after the fall); (3) provide proper footwear (however, per the nurse’s notes, non-skid footwear was not provided until after the fall); (4) observe for safety (however, staff failed to sufficiently monitor Plaintiff—see below); (5) provide a clutter free environment (however, per the nurse’s notes, this was not done until after the fall).

In addition to the staff’s care plan failures, staff also usually failed to respond to Plaintiff’s call light in a timely manner. According to a nurse’s note dated July 17, 2009, Plaintiff had a “good understanding” of the use of her call light. However, getting the staff to respond to her call light was another matter. Further, the staff failed to conduct bathroom checks on a regular basis. In addition, the toileting assistance that the staff provided was inadequate. And the staff failed to sufficiently monitor Plaintiff, as described below.

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