IDPH has cited Bella terra Elmhurst nursing home after a resident there suffered a fractured femur and dislocated knee in a fall.
One of the well-worn paths for injury to nursing home residents is having one person do a two-person job (see here, here, here, here, and here for examples). Most often, this occurs because the staff member involved is taking a shortcut in the care of the resident, usually because the nursing home is understaffed. This incident shows that this can also happen when there is a breakdown in the process by which the care needs of the residents are communicated to the staff on the floor.
The resident at issue suffered a dislocated shoulder and underwent a course of physical therapy. At the time the resident was discharged from physical therapy, there was a recommendation by the therapy for the resident to have transfers with the assistance of two staff members using a gait belt. The nursing home incorporated that recommendation into the resident’s care instructions which were kept in a binder at the nurse’s station.
On the day of this nursing home fall, there was an aide from a staffing agency who was assigned to care for the resident at issue. It was that aide’s first time caring for the resident, so she asked the nurse assigned to the resident what her transfer status was, and was told that the resident required assist of one with a gait belt. The aide was unaware of the existence of the binder. The nurse, who was caring for the resident for only the second time, claims that she was told during the nurse-to-nurse report during change of shifts that the resident was assist of one with transfers. However, she did not verify this in the binder.
Acting on the information provided, the aide attempted to transfer the resident from her bed to her wheelchair without the assistance of another staff members. Immediately after the resident stood up from the bed, her legs gave out from underneath her, and the resident was lowered to the floor using the gait belt. The aide got a nurse who helped the resident get back into bed using a lift.
The resident had persistent complaints of pain before she was sent to the hospital where x-rays showed a subcapital femur fracture (a type of hip fracture) and a dislocated knee as a result of the fall.
One of the interesting points about this is that the aide and nurse who were charged with caring for this resident were both agency staff, meaning that they were not necessarily people who regularly worked in the facility. When agency staff is brought on board, they must be trained sufficiently in how things are done in the nursing home. The aide did the right thing by asking what the transfer status was of the resident, but was unaware that there was a clear answer in the binder – because she did not know that the binder existed.
The use of agency staff and the failure to invest the minimal time necessary to properly train them is a sign of a nursing home that takes shortcuts in the care of the resident. Sadly, this is consistent with the basic 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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