Death from an avoidable fall in a CHSLD

A 96-year-old senior died of a fatal fall without witnesses in a CHSLD in Trois-Rivières, even though she had to be accompanied during her travels, deplore her relatives and a coroner.

• Read also: Over 1,000 seniors dead from falls in two years

Simone Boisvert fell seven times in less than a month at CHSLD Louis-Denoncourt, from August 28, 2020 to September 22, 2020.

“It’s like rendering normal. They fall, they end [leur vie] the same”, drops with discouragement his daughter Josée Villemure, aged 59.

She and her two sisters never got to know the true circumstances surrounding their mother’s death.

Nevertheless, his death was the subject of a coroner’s inquest. In the report, Me Mélanie Ricard points out that the recommendation made by a physical rehabilitation technologist who assessed Ms. Boisvert after several falls had not been followed.

The latter asked that Ms. Boisvert’s movements be supervised by a service aide.

“The Fall could have been avoided”

“I consider it entirely legitimate to believe that the fall which resulted in a fatal injury to Ms. Boisvert could have been avoided if the recommendations had been followed as formulated and her movements had been supervised,” she wrote.

Moreover, the eldest even made three falls after the last recommendation of the technologist, specifies the report.

The coroner is also surprised that the establishment has exceeded the recommendations of this professional and that it justifies the breach by qualifying the risk of falls as inevitable.

Indeed, in its own internal investigations following the death, the CHSLD points out that a fall occurred in the presence of one of Ms. Boisvert’s daughters.

This incident occurred when her mother was alone in the bathroom, they said.

The latter took turns to ensure almost constant supervision of their mother. But the fatal fall occurred just before one of them arrived on the fateful morning.

Not normal

“Nobody knows what happened, it’s not normal,” laments Suzy Villemure.

She says that when she arrived, no employee had witnessed the fall or could explain what had happened.

“Not my shift, not my shift,” they repeated, according to her.

However, his mother was found in the room of another resident, with a dislocated shoulder and a cerebral hemorrhage following the impact. Photos taken by the family show several bruises.

The coroner’s report indicates that “the nurses’ notes state that Ms. Boisvert had been seen approximately two minutes before her fall by a nurse while she was walking alone with her walker in the corridor, without supervision”.

“We asked for surveillance, add the two sisters. Not a nurse or attendant, but just a security guard. »

A “minimum to do”

” [Les établissements] have a mission to protect [les aînés]and cuddly, there was a minimum to do to protect her and it was not done, ”laments Suzy Villemure.

They also deplore that their mother was “stunned” by all the medication she had been taking since her arrival in the establishment.

The coroner, for her part, recommended that the CHSLD apply “to the letter and implement the recommendations made by the physical rehabilitation professionals”.

Technology to prevent accidents

Several technological tools exist on the market to help employees and residents reduce the risk of falls (see boxes). However, Quebec is behind in terms of technology, believes Philippe Voyer, researcher at the Center of Excellence on Aging in Quebec. “There need to be more tools, but that’s not going to solve everything. It’s multifactorial,” he says, advocating better staff ratios.

Moreover, several fatal falls have occurred in CHSLDs or residences while the equipment was defective or not activated, several coroner reports showed.

Peer Program

Seniors can sign up for this free system, which makes an automated call every day at a pre-determined time to make sure everything is okay.

After three unsuccessful attempts, an alert is triggered and the relatives of the eldest are contacted.

Several seniors who spent hours on the ground could have been found earlier and saved, had they been enrolled in the program, coroners noted.

emergency bell

Emergency bells can be installed in the resident’s apartment or room, to allow him to call for help if needed. Doorbells are often installed in the bathroom.

The only problem with this system is that the person in distress must be able to get there.

Inflatable belt

This new Swiss technology protects seniors against femoral neck fractures thanks to an electronic detection system that triggers the inflation of two bags during a fall, before impact with the ground.

It is therefore suitable for seniors who like to walk a lot. However, the belt is not yet available in Quebec, but Philippe Voyer, a researcher at the Center of Excellence on Aging in Quebec, would like it to be.

Surveillance cameras

The multiplication of surveillance cameras in the rooms of the residents and the common places of the residences would help to prevent falls and also to make it possible to rescue fallen seniors as quickly as possible.

When an employee monitors the premises remotely, it is easy to see if a resident is awake or up, and therefore to assist them in preventing a potential fall.

Call bracelet or necklace

Seniors at risk of falling benefit from wearing these portable systems so that they can call for help in the event of a fall.

One of the problems with this device, however, lies in the resident’s desire to wear it at all times.

Many seniors with cognitive impairment refuse to wear it.

Ringing mattress

When activated, the mattress rings as soon as the resident gets out of bed. Thus, employees can hear the ringtone, and come to the person’s bedside to prevent them from falling.