IDPH has cited and fined Avantara Lake Zurich nursing home after a resident there suffered a 7.5 inch long lower leg wound while being transferred from his wheelchair to bed.
One of the basic tasks performed by aides in a nursing home is transferring residents. Some of those transfers are done with a lift; others are done manually. Either way, these transfers have to performed properly, with the right help or right equipment or disaster is the likely result. Most often, the net result is a nursing home fall resulting in a brain bleed or hip or other fracture. Here the net result was a skin tear, 7.5 inches long which required 35 staples and 9 stitches to close .
How did this occur?
The resident was being transferred from his wheelchair to his bed with the assistance of a single aide. The resident had been assessed on his Minimum Data Set (MDS) as requiring maximum assist of two staff with transfers. Facility policies also required the use of a gait belt with assisted transfers, but none were in use on the day of this resident’s injuries.
As the resident was being moved into position, he told the aide that he was not in the right place, but she assured him that it was okay to proceed anyway. No gait belt was in use. As he was being moved into the bed, his leg got caught on a portion of the bed frame of bed rail, resulting in the skin tear. As we age, our skin becomes thinner (which is one of the reasons that nursing home residents are susceptible to developing bed sores).
There was immediate bleeding, and the resident was sent to the emergency room where the wound was closed. However, by the time that the survey was conducted by the State, it was apparent that the wound was not closing properly, and is requiring the care of a wound care specialist.
Why did this happen?
There are the immediate reasons, and then the deeper reason. The resident was assessed as requiring two person assist with transfers and this was the level of care that the nursing home certified to the federal government was being provided. The MDS forms part of the basis by which the nursing home is reimbursed, so it must be completed under penalties of perjury. Here, the was one person doing what the nursing home said was a two-person job. Further, the resident gait belt was not in use despite a facility policy requiring its use. The gait belt allow the staff to better control the movements of the resident and would have helped avoid the contact with the bed frame. Finally, the aide ignored the resident when he said he wasn’t in the right position. Many nursing home residents who do not have cognitive deficits are well aware of what their care requirements are, even if they can’t manage it themselves. Ignoring the warnings of the person most knowledgeable about the resident’s care needs is setting yourself up for failure.
The deeper reason is that the nursing home was likely understaffed. When you see the staff take shortcuts like going without a gait belt or having one person do a two-person job (a well-recognized formula for disaster- see here, here, and here for examples), that is a sign of an understaffed nursing home. When there is not enough help, the net result is that shortcuts are routinely taken in the delivery of care, with the avoidance of disaster being good luck rather than good care. Relying on luck is not a substitute for proper care.
Sadly, understaffing a nursing home is a basic part of the nursing home business model. 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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