IDPH has cited and fined Alden Courts of Shorewood nursing home after a resident there broke both legs during an unsafe transfer.
Nursing homes must complete a document called the Minimum Data Set (or MDS) for each resident in the nursing home. The MDS is supposed to reflect how much care the resident is receiving from nursing home staff. It is part of the basis by which the resident’s acuity level is determined and therefore is part of the basis used to determine how much money the nursing home receives for caring for the resident. Because of the financial implications of the MDS, the staff signing are required to sign it under oath.
Depending on how the various sections of the MDS are completed, this can trigger a Care Area Assessment or CAA. When an area on the CAA is indicated, this is supposed to serve as a trigger for the nursing home staff to care plan for that area. For example, an entry on the MDS indicating that the resident has a history of recent falls, may trigger the CAA and direct the nursing home staff to put a fall prevention care plan into place.
The care planning process has six steps: (1) an assessment of the risks to the health and well-being of the resident, (2) development of a care plan, (3) communication of the care plan to the staff charged with carrying it out, (4) implementing the care plan on a day-to-day, shift-to-shift basis, (5) evaluating it effectiveness on an ongoing basis, and (6) revising it if the resident’s care needs change or if it proves to be ineffective in practice.
Here, the resident’s Minimum Data Set reflected that she was receiving assist of two with transfers. Accordingly, the resident’s care plan also indicated that she was to receive extensive assist of two with transfers.
On the day of the incident, the resident was being transferred from her bed to her wheelchair with the assist of a single aide. The aide was attempting the transfer with a technique known as a pivot transfer. In a pivot transfer, a gait belt is placed around the midsection of the resident, and the resident is helped to a standing position and pivoted from where they are sitting to where they want to go – in this case, from bed to wheelchair. In order to do this safely, the gait belt must be applied properly and the resident must be able to bear weight sufficiently to assist in the pivoting portion of the transfer.
As the transfer got underway, the gait belt slipped upwards on the resident’s torso. The aide grabbed at the resident’ pants which tore and the resident was not able to bear enough weight to stay upright so the aide lowered the resident to the floor and left to get a nurse. X-rays showed that the resident suffered fractures of both tibias (the weight bearing bone of the lower leg) just below the knee.
During the investigation, the state surveyor learned that the usual practice at this nursing home was to have the number two posted above the resident’s bed when a two-person assist was required. There was no such positing for this resident until after this nursing home fall occurred. As a result, sometimes two staff were used for transferring the resident, sometimes not.
Here the nursing home accurately assessed the resident’s need for help in transferring and came up with a reasonable care plan to meet that need. However, the contents of the care plan were not properly communicated to the staff charged with carrying it out. As a result, the resident was not transferred in a safe manner and the injury the care plan was intended to prevent occurred.
Past that the fact that the care plan was not properly communicated to the staff means that there were a number of days prior to this when the care plan was not being followed, and if there are deficiencies in how the contents of care plans are communicated to the staff, then there may be a systemic problem at this nursing home.
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