IDPH has cited and fined Alden Valley Ridge nursing home in Bloomingdale after a resident there suffered a broken leg in a fall due to an aide’s failure to use a gait belt.
Properly run nursing homes invest significant effort into determining what kind of help and assistance residents require to assure their safety and well-being. When the required levels of care are properly identified but then not provided, unnecessary injuries are the very predictable result.
The resident at issue had weakness associated with a prior stroke and was considered a fall risk. Her Minimum Data Set indicated that she required extensive one person assist with ambulation, transfers, and toileting. “Extensive assist” includes actually physically assisting and supporting the resident during the activity.
When a resident requires extensive physical assist, use of a gait belt is required to perform the activity safely. A gait belt is a canvas strap which is applied to the midsection of the resident and used by the aide while assisting the resident. It allows the aide to effectively provide physical support to the resident and to either help the resident maintain and upright position or control the fall should a resident begin to fall or lose their balance. The nursing home’s policies and procedures required the use of a gait belt on residents who required physical assistance.
On the day of this nursing home fall, the aide had brought the resident to the bathroom and was assisting her in getting an adult brief on. The resident was standing by the toilet holding onto a grab bar. The aide had a gait belt, but it was not on the resident. It was in the aide’s pocket. The aide explained to the state surveyor that it was a matter of judgment as to whether to use the gait belt, and that it was her judgment that this resident did not need one.
The resident told the aide that she could not maintain her standing position and that her legs were giving out. The aide tried to get the resident to the toilet or to get a wheelchair over to help the resident, but the resident fell to the floor. She later complained of leg pain and when x-rays were done, they showed a fractured femur.
The whole point of performing assessments and determining the level of care that a resident receives is so that it is not left to random chance. The same would be true of having policies and procedures. When staff decides that providing the level of care that a resident truly needs is a matter of judgment, the residents’ care is left to random chance – what did a particular staff member see and what did they think about what they saw on a particular day? When a staff member provides substandard care but avoids injury, that becomes part of the basis for judgments made down the line – not realizing that the lack of a catastrophic outcome was a matter of good luck, not good care. And having gotten lucky once, that becomes a tempting option in providing care going forward. The net result though is that residents are exposed to unnecessary risk of harm.
Unfortunately, that was what happened here. A staff member disregarded what the assessments had said about the resident’s care needs, disregarded the facility’s policies and procedures, and substituted her own judgment, much to the detriment of the resident.
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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