This blog has addressed a number of safety and quality of care items that family can be observant for at a faciity either pre admission or after admission. This is another one of those obvious situations that is an indicator of a facility that does not have systems in place and should be suspected for qualiy of care issues.
While sitting in the lobby of a free standing memory support facilty, an unsteady resident walked to the lobby area. The resident had a very unsteady gait and his balance was obviuosly poor. He did not have an assistive device of any kind. Staff passed him in the hall as he unsafely ambulated toward the lobby. On arriving in the lobby, he turned, lost his balance and fell to the floor. The receptionist was in direct line of sight of him, but apeared not to have seen him fall nor did she respond to him being on the floor. He laid on the floor for nearly 10 minutes before someone found him.
Once he was found on the floor, five (5) staff appeared. They stood around him talking and trying to decide what to do. One of them leaned down to ask him if he was hurt. He said he was not. The five (5) people could not decide how to get him upright. They lifted him by his ams and the belt on his slacks. Once they got him to his feet, he trotted off with the same balance and gait issues and no supervisior or staff attendance
This was a totally unsafe situation that no one recognized. The resident should have been supervised as he walked. He was definitely unsafe to walk independently. The care plan should have included fall risk approaches for him that were consistent with his needs. These interventions should have been disclosed to all staff. Further, with dementia the likelihood of him remembering not to ambulate alone was non existant. Once he was found on the floor, he should have been assessed to assure that he had not sustained any injury. Only then would he have been helped up. He should have been moved to the upright position with a mechanical lifting device. The staff should have used a gait belt to help stabilize him as he walked away.
Watch for unsafe management of residents in the facilities when you are visiting. There were other family visitors around and they observed this fiasco. As a facility, this lack of assessment, monitoring and planning spoke for itself. No amount of marketing can offset the actual experience seen by visitors and family members.