Despite a bed alarm and other safeguards, Rudella Reiners, 89, got up undetected, fell and broke her hip. She died five days later.
Rudella Reiners couldn't safely walk on her own.
With her advanced osteoporosis, dementia and a history of falling, the staff at Grand Village nursing home in Grand Rapids put up a lot of safeguards -- a bed alarm, a motion sensor, a sound monitor, a perimeter mattress -- and kept a bathroom light on at night.
Eventually, they moved Reiners to a room where they could watch her more closely.
Still, in the middle of the night in mid-2006, Reiners got up and walked, according to a state investigative report. Alarms sounded, but nobody heard them.
Reiners apparently moved a trash can into the hallway and took a bad fall.
Two nurses aides and a licensed nurse were working in her unit -- a staff of three to cover 48 residents, according to the report. But one of the aides had gone to another part of the building to cover staff breaks, the report said. The other two were helping a resident in a different wing.
There was no one at the nurse's station to hear Reiners' alarms go off, the report said. Eventually, the nurse heard Reiners yelling and the alarms screeching. Reiners lay on the floor with a broken right hip.
At the emergency room she "was completely out of it," her son Steven Reiners said. "Her eyes were rolling."
A former school administrator, he took a clipboard to the nursing home that night to talk to staff about what had happened. It took him more than 10 minutes to find anyone, he said.
Surgeons tried to repair his mother's broken hip, but Rudella Reiners, 89, never really recovered. She was "agitated, confused and her pain was difficult to control," the report said. She stopped responding and stopped eating. She died five days after the fall.
State investigators found Grand Village neglectful. An investigator went to the nursing home weeks later and verified that two alarms couldn't be heard from the nurse's station or other wings of the unit.
The facility argued that Reiners was "spry" and may have taken only seconds to move 31 feet on the night of the fall, according to a dispute resolution report on the case.
The state monitored the facility for about two weeks. The home made corrections, including adjusting staffing, reviewing time management and switching out alarms or changing batteries on weak-sounding alarms. The home was fined $1,500.
Steven Reiners has filed a lawsuit.
A representative of Shoreview-based Ecumen, which manages Grand Village, said he couldn't discuss the case because it's in litigation, but he said Ecumen supports the care given at the nursing home.
Senior Vice President of Operations Mick Finn wrote in a statement that Ecumen dramatically minimizes fall risk through various safeguards. But "absent break-through innovation, eliminating that risk means ripping away a human being's independence. ... We'll take managed risk over dehumanization every single time."
Steven Reiners said he wants nursing homes held accountable. "Someday I'll probably be in that same rest home."
Pam Louwagie • 612-673-7102