IDPH has cited and fined Fairhaven Christian Retirement Center nursing home in Rockford after a resident there suffered a fractured hip when she was dropped from a lift during a transfer.
Used properly, a mechanical lift is a great tool for providing care for nursing home residents with severe mobility deficits. They allow residents to be moved safely from bed to wheelchair, wheelchair to chair or toilet, etc. They allow residents to be moved safely while being bathed. They also prevent injuries from being twisted while being moved manually. They save wear and tear on the backs, knees, shoulders, and so forth of the staff and help prevent injury to staff as well.
Of course, the key phrase in that first sentence of the paragraph above is “used properly.” When not used properly, they set the stage for serious injury to the resident. Proper use includes having two staff members operate the lift (see here, here, here, here, and here for examples of what happens when one person does a two-person job); it includes safe operation of the lift itself (see here and here for examples of what happens when the lift isn’t used properly); and it includes making sure that the lift itself is in good condition and that all of the slings and accessories are in good condition and appropriate for use (see here, here, and here for examples for when that is not true).
This incident shows what happens when you have one person doing a two-person job.
The resident at issue had significant cognitive and mobility impairments such that she required assistance of two staff members with transfers. Further, the resident care plan called for the use of a mechanical lift with two staff assist. Having the care plan call for two staff members to participate in transferring the resident with a lift is consistent with prevailing safety practices in the long term care industry, as safe operation of a lift requires one staff member to operate the controls of the lift while the other staff member keeps the resident safe and properly positioned in the sling.
On the morning of this nursing home fall, an aide was walking down the hallway when she heard a loud noise come from the resident’s room. She entered the room to find the resident on the floor lying on the top of the legs of the lift with blood coming from her head. The only other person in the room was another aide. The aide explained that she was transferring the resident from her wheelchair to bed by herself. While the transfer was in progress, the resident rolled to the right and fell from the sling. Because there was only a single staff member involved in the transfer, there was no one who was able to help keep the resident in the sling.
The resident was transferred to the hospital where she was diagnosed with a fractured hip. Surgical repair was attempted, but the fracture was complicated and proved to be nonrepairable. The resident was returned to the nursing home for comfort measures, including pain management.
This is another example of the disaster that results when one person attempts to do a two-person job. Not only was this a violation of the resident care plan, there were also facility policies in place which required the use of two staff for transfers with a mechanical lift. And the nursing home not only had a policy in place, but also provided the staff with radios to call for help with transfers. The aide involved clearly knew that this was not something she should be doing, as she told the first person to enter the room, “I always ask for help.” Sadly she didn’t do so this time, and the resident paid the price.
When you have staff taking shortcuts in the care of residents, this raises the question as to whether this is an understaffed nursing home. Unfortunately, understaffing a nursing home is a feature 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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