IDPH has cited and fined Elevate Care of Waukegan nursing home after a bedbound resident there suffered a fractured arm while being repositioned in bed.
Turning and repositioning residents is a staple of care in a nursing home setting. One reason that it is so crucial is that it helps prevent the development of bed sores. However, like everything else in a nursing home, it must be done right, and as we have seen (see here, here, here, here, and here for examples) having one person do a two-person job is a formula for disaster. And this proved true here once again.
The resident at issue was bedbound and severely cognitively impaired to the point that he was unable to move his extremities. His care plan called for assist of two with bed mobility and transfers. However, when the resident’s family was interviewed by the state surveyor, they reported that the resident was often repositioned with a single aide because the nursing home was understaffed.
On the day of the incident, the resident was sent to the emergency room for evaluation of swelling and discoloration of the left shoulder. X-rays showed that he had suffered an acute fracture of the humeral neck (the portion of the upper arm that inserts into the shoulder) and an acute fracture of the proximal humeral diaphysis (the shaft of the upper arm). The aide assigned to the resident on the night shift before the injury was discovered admitted to the state surveyor that she routinely repositioned the resident on her own.
Of interest, the Director of Nursing told the family that the injury was due to brittle bones, but the nurse practitioner and orthopedist’s physician assistant both told the state surveyor that the injury was one which required the application of force to occur, even if the resident had a bone density disorder.
Obviously, there was a clear violation of the resident care plan which resulted in this fracture. The reason that two aides are sometimes required is to assure safety (so that the resident isn’t accidentally rolled out of bed) and to minimize the forceful tugging and pulling which is sometimes required to move someone who is incapable of voluntary movement. Residents who are bedbound do tend to have reduced bone density as a result of inactivity, and this can predisposes them to fractures. However, this pattern of fractures (especially with two separate fractures) is likely the result of improper handling of the resident in repositioning the resident with a single aide rather than the two called for in the resident care plan.
One person doing a two-person job is a hallmark of an understaffed nursing home and this was something that was confirmed with the family’s own observations. Sadly, understaffing is a feature, not a bug in 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.
Other blog posts of interest: