IDPH has cited and fined Heritage Health of Hoopeston after a resident there suffered a broken arm in a fall brought on by the failure to follow the resident’s care plan.
The care planning process is how much of the routine care provided in nursing homes gets delivered. There are six steps to the care planning process. First there is an assessment of the risks to the health and well-being of the resident. Second a care plan is developed which identifies a series of steps or interventions which are to be done to reduce the risks to the resident. Third, the care plan is communicated to the staff who are charged with carrying it out. Fourth, the care plan must be implemented on a day-to-day, sift-to-shift basis. Fifth, the effectiveness of the care plan must be evaluated on an ongoing basis. Sixth, the care plan must be revised if it proves to be inadequate or if the care needs of the resident change.
The resident at issue was identified as being at risk for falls. Two of the interventions that were listed in her care plan were: (1) transfer the resident with two staff when suffering from acute illness and (2) place non skid strips on the floor.
In the days leading up to the nursing home fall, the resident was diagnosed as suffering from cellulitis of the right leg and from covid. As a consequence of her covid diagnosis, she was placed in another room. According to her care plan, the nonskid strips should have been placed on the floor of her room, but were not. On the day of her fall, she was being transferred from her recliner to the bathroom with the assistance of a single aide. As the aide was transferring the resident, the resident’s feet began to slide out from under her due to the lack of nonskid strips on the floor. The aide attempted to support the resident by holding her from under her armpits, but there was a loud cracking sound and the resident experienced immediate pain and was unable to move the arm. She was brought to the hospital where x-rays showed that she suffered a broken arm and a separated shoulder.
The two elements of the care plan discussed above were violated, and the fall and the injury to this resident were the result. Even though the resident was placed in a new room due to her covid diagnosis, the nonskid strips on the floor were still required. The lack of the nonskid strips on the floor led to the resident’s feet sliding out from under her, leading to the loss of balance. When the one aide attempted to stop the fall she was working alone and was not able to. Having a second staff member present for the transfer likely would have prevented the injury to the resident.
The most direct and obvious cause of the injury to this resident was the violation of the care plan. However, understaffing of the nursing home is a likely culprit as well. The aide involved admitted to the state surveyor that she knew that there was supposed to be a second aide assisting with the transfer but she tried to get it done on her own. When you have staff taking shortcuts in the care of residents, understaffing is a likely culprit. Sadly, understaffing is a feature, and 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.
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