Falls and care homes - any experience?

[woodstack]

My dad had a massive stroke last year and after 4 months in hospital he has just moved into a nursing home. Due to the stroke he has severe cognitive impairment and has left side neglect. He cannot move his left arm, walk or bear weight.

He firmly believes he can walk and frequently tries to get out of bed and/ or his chair (by shuffling to the edge and pushing on the arm). This was well managed in hospital as he had bed guards and a lap belt in his wheel chair - he did not fall once. The nursing home he has moved to are saying that they cannot provide bed guards or lap belts at all. They lower his bed and provide crash mats either side instead and an anti-slip mat on his chair. In the 48 hours he has been there he has fallen out of his chair once and has been found off his crash mats 3 times in the middle of the night. I understand that there are risks associated with bed rails/ lap belts etc but cannot see that these risks are greater than him constantly falling.

It is early days at the care home and I am hoping we can work on strategies etc but having bed rails and a lap belt would so very much improve his quality of life and reduce the risk of broken bones and serious injury. At the moment he is basically living on a lowered bed on the floor which is awful for his dignity, dreadful for visitors, means he cannot access normal meals at a table, attend activities or participate in the wider life of the home at all. Has anyone any experience of this?? Is this common?

That sounds difficult for everyone. The bedrails are a form of restraint so the staff will need a risk assessment and permission to use them. The lap belt is also a form of restraint so will need the same, also people can slide under the belt, the chair could tip over with the person still strapped in, I've never seen a lap belt used on a normal armchair, only on a wheelchair that has been assessed properly, maybe the staff are considering this. If he had a wheelchair then he could attend activities, is he able to sit in an armchair and have meals if staff supervise him. Has he been seen by the community physio or o.t, to assess his sitting, balance, chair assessment. Could his bed be higher when he has visitors.

He needs a best interests decision to be made that he should be restricted to keep him safe, a nursing home should be used to this.

sorry, no idea where that came from.
seatingmatters.com/sorrento-2/

I used to work in a nursing home, and we weren't allowed to use bed rails without very strict protocols in place. There is a fine line between keeping someone safe and abusing their rights, sadly. Even though the reality is utter madness.

You need to have a chat with the home manager and express your concerns.

My dad has had bed rails in his care home since he broke his hip last Autumn.
Didn't know there was any sort of contentious issue on the subject. He accepts it's to keep him safe from falling during the night. If he wants to get up for the loo, he rings and people come to assist.
Were we meant to sign something then???

Bed rails work well for people who are at risk of falling out of bed. But for people who think they can walk they are more of a risk as the person is likely to climb over the bed rails & then fall from a greater height.

Ohdear it's fine if the person has the capacity to understand why rails etc are needed and can give consent, its when they don't have the mental capacity that it becomes more contentious

I'm an occupational therapist and have been involved with going into care homes to look at seating etc, may be worth asking for an OT assessment. Unfortunately I've not known many care homes to employ OT's, but it's worth a try. They may be able to source one from somewhere 😀 Good luck, hope it gets sorted out ASAP!

www.cqc.org.uk/guidance-providers/learning-safety-incidents/2-unsafe-use-bed-rails

Bed rails can be dangerous for someone with a cognitive impairment who thinks they are stilll mobile -they can try and climb over them which is more risky than if they weren't there. It would also be considered a form of restraint.

You can get ultra low beds that combined with a crash mat would really lower the risk of injury from falls - there is one called the floor bed by accora. I would also suggest a bed exit monitor and chair exit monitor so staff would be alerted straight away if he falls.

I worked in a nursing home, there needs to be risk assessments done, as bed rails and the lap belt are seen as restraints. We had bed rails for individuals who couldn’t climb out of bed, but were at risk of rolling out. If the person wants to try and climb out then the rails cause more danger.

I did care for many individuals with advanced dementia who literally had a bed on a floor with crash mats. I agree it doesn’t look nice for them or to visitors, but is a last resort to save injuries. Arrange a chat with whoever’s in charge, and they should explain if they’ll bring him out for activities/visitors etc.

If he has a severe cognitive impairment and lacks capacity to consent to those restriction you named then a Deprivation of Liberties Safeguards (dols) would need to be applied for to the court. I'm hoping the home already know this- as a residential home it would be their responsibility to make the application to court.

Is the placement funded by social services? If so could this not be coordinated by his case manager/social worker? If he is a self funder, the local authority can also provide you with information and guidance if you need it.

Thanks all. We definitely need to speak to the home about options... Finding a safe way to stop him falling out of the chair is the priority I think (thanks for the chair link wigglypiggly) otherwise he will be bed bound.

With regard to DOLS - would one be necessary given that he can't walk? - in that the "restraints" wouldn't be depriving him of his liberties (because he hasn't got any anyway ).

In my experience if a resident lacks capacity and is on dols then all their care is given in their best interests and a dols consent form is used for every section of that care, one to consent to living in the home, one to consent to have help with washing etc. In something like this maybe he will need a dols consent for staff to use the hoist to help him out of bed, to sit in an armchair which may need tilting like the one I linked, to have a lapstrap added to a specially measured wheelchair, to be supervised during meals and activities, having bedrails and bumper pads in place. . Does anyone have power of attorney and ask the home if he has had a capacity assessment. We had to buy the chair, about 1.5k, carehomes don't have access to as much equipment as hospitals so things do take a bit longer, plus he would need to have assessments first.

@woodstack basically if he is restricted in anyway, regardless of his abilities, then an application to court would have to be made. This also relates to decisions relating to his care and support needs and where he receives this care and support. Happy for a PM if you need any support (adult social worker here)

What everyone else says, and SpanielEars is right; the reality is rubbish. Of lot of the pedantry involved appears to be misdirection.

It's true, some folk can clamber over bed rails and nearly kill themselves. In some ways, the bed lowering into the ground thing works better as it avoids that - a bit rubbish though, as at one care home I visited nr Kingston, Surrey, however, as anyone restricted to bed all day would be on the floor and unable to see out of the window overlooking the Thames!
And how would they watch TV in bed, neck would get cricked.
And how does it work for a death bed moment, family all gathered round, would they all be sat on the floor too?

Surely him being on the crash mat is not actually a problem if the bed was lowered to the floor?
Not sure about the chair situation.

Maybe make for regular night checks, so he hasn't fallen and come to harm, though the bed situation could be worse imo.

Many care homes do allow the bed rails thing, so you could change, but I'm in two minds.

BTW sorry to break it to you but, erm, residents in your dad's position who do break a leg... evidence suggests they get 'disappeared'. No, I'm not kidding. It is simply not sustainable to keep someone alive in that situation, esp if they are deemed to have lost mental capacity anyway.
How it is done, I don't know - probably the old opiates trick. But two care home residents I know who suffered a breakages mysteriously died within weeks of that, and dementia or not, you don't die of a broken hip/leg, do you.
Main way of killing the elderly off to save money is forced dehydration, of course. It's not quite the Liverpool Care Pathway of course, so not quite illegal.
And unlike opiates, you won't prove anything via a post mortem.

If anyone has power of attorney for his health and welfare the home shouldn't need to apply to the court of protection for any decisions that are made in his best interests. The beds that lower to the floor have controls that allow that bed to be lowered right down from waist height so don't worry about having to sit on the floor. If he likes to watch tv then obviously that could be placed on a lower table. Ignore some of the comments made by previous poster. I hope you get it all sorted out and that you dear dad settles in.

Newspaper, can you link the evidence you have quoted

I don't see why anyone should ignore my comments, wiggly.
My point is that if the family did not know to get LPA in Health and Welfare, then the Council is the decision maker for their care, not the family. In 7 Surrey care homes I never knew any local authority go to the Court of Protection for any decision making; they did exactly as they pleased. That said, it appears they wanted to go to the Court of Protection regards me - they can have family members barred from seeing relatives, and in that case will request the care home go on a fishing expedition against visitors to see what will turn up, the visitor in question will be dimly aware of something up, but they won't know what hit them.

This happened after I 'whistleblew' or rather exposed a care home to the local press; it nearly killed my mother but nobody has been held responsible. I later found out a month before she nearly died that the CQC had failed the home on all counts, but they didn't tell us, just let the body count mount up. It saves money, you see. I uncovered the truth myself about their inspection and it came out eight months later.

Yes, I know the beds lower from waist height. I assume, however, that if one is visiting a relative, then you have to raise the bed to speak to them, then lower it again if you leave the room briefly.
The TV would have to be on a very low table if the bed is on the floor.

No, I will not link to 'evidence' thank you, which bit are you complaining about specifically? If you Google 'dehydration' and 'care homes' you see a lot to hint about the Liverpool Care Pathway, but it's too big a story for most papers. Still, if you Google Daily Mail and the Gosport, and Prof Pullicino, consultant neurologist, you get a bit of what is going on.

The opiates thing is all Gosport related.

The stuff about breakages is anecdotal from what I have observed. No, I will not name the care homes, I don't feel particularly actionable today.

DOLS applies if:

1. The person doesn't have capacity in relation to their residency, care and treatment

AND

1. They're under constant supervision and control AND not free to leave

Sounds like your Dad meets the acid test to me and the home should be making the application.

It also should be fairly easy to get an OT out to look at the other issues- any form of restraint (restriction) will be looked at within the DOLS.

We have experienced both of these issues - but with carers at home not in care home. Both my parents need 24 hour care and neither are mobile or continent.

For reasons too many to go into, we bought Mum's hospital bed. And as a result were able to have the rails (with padded bumper guards).

My Dad's bed was provide for him and we were told that they couldn't use rails for all the reasons given above. However, although the bed lowers to close to the floor, he was still at least a foot above the crash mat. He would be frequently was found, slumped out of bed at horrible angles - head on the crash mat, feet in the bed, his body twisted.

After several months we managed to get the OT and district nurse to do a 'cot sides' assessment and agreed that we could have a standard hospital bed and cot sides with bumper, but I had to sign a disclaimer to take responsibility if Dad hurt himself! Its been fabuloues ever since.

My mum (long term alzheimer's and recent femur fracture), gets restless in her chair (but can't stand or weight bear). Because my Dad needs 2 carers when being hoisted etc. this meant that mum would be in her room alone at this time. The carers wanted to put a lap belt on so she didn't slip and fracture another bone - but were not allowed because its a safeguarding issue. They were advised that mum would need to be hoisted back into bed, while they went to care for my Dad ...!!
We have now been provided with the most incredible chair that definitely cost over £1k, which tilts (rathr than rise / recliner) so if left alone they tip her chair . A belt on her existing chair seemed a much simpler (and vastly cheaper option ....)

Whilst I am immensely glad there are safeguards in place - they do seem to have replaced common sense.

I can't work out why hospitals are ok to operate under different rules? All the beds had sides on and there wasn't an issue. I feel your frustration OP