IDPH has cited and fined Addolorata Villa nursing home in Wheeling after a resident there fractured a hip in fall that occurred while he was being transferred by a single aide rather than the two staff that he needed for safe transfers.
One key part of a nursing home chart is the Minimum Data Set (MDS). This records a wide array of information about the resident’s condition, activities, abilities, and care needs. The data on the MDS is certified under oath as being true by members of the nursing home staff. The reason that it is completed under oath is that is forms part of the basis by which nursing homes are reimbursed for the care that it provides to the resident. Therefore, the MDS should accurately reflect not only the care that the resident needs, but the care that the nursing home is actually providing.
The resident at issue had a number of chronic conditions including Parkinson’s Disease, muscle weakness, and dementia. His MDS certified that he required the assistance of two staff members to transfer from bed to chair. He was assessed as being at very high risk for falls.
On the day of this nursing home fall, the resident was being transferred from his bed to a wheelchair by a single aide. Having one person doing a two-person job is a well-worn formula for disaster in the nursing home industry (see here, here, here, here, and here for examples). This also happened to be this aide’s first day working with this resident and she advised the state surveyor that she was not instructed on the resident’s care needs.
While the aide was in the process of transferring the resident from his bed to his wheelchair, his feet got tangled in the footrests to his wheelchair. He was too heavy for the aide to control, and she attempted to lower him to the floor, but could not control his descent. He hit the floor and and banged his head against the dresser, resulting in a laceration to the head. Given the resident’s pain in hip and the fact he had head trauma while taking blood thinners, he was sent to the emergency room.
At the hospital, x-rays showed that the resident was suffering from a broken hip. However, the decision was made against surgical repair. The decision to not have surgery done means that the resident will likely lose his ability to ambulate and bear weight on that leg which increases the risk of complications associated with immobility such as the pneumonia and the development of bed sores.
One of the striking features of the citation was how poorly trained the staff were. The surveyor noted falling leaf symbols (used in the nursing home industry as a symbol for fall risk residents – Let’s End Avoidable Falls) by the doorway, but none of the staff was able to explain what it meant. Many of the staff admitted that they received minimal onboard training and were unable to explain why or how certain fall prevention steps were being taken. Sadly, poor training of staff is a common feature of the nursing home business model because properly training staff costs money.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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