IDPH has cited and fined Sandwich Rehab nursing home after a resident there suffered a broken ankle during an unsafe transfer from the toilet to her wheelchair.
The resident at issue had cognitive issues, muscular weakness, and a right foot drop. These are factors which would have made her at risk for falls. In the normal course of things in a well-run nursing home, this would have resulted in the development of a fall prevention care plan which would have stated what kind of assistance the resident required for transfers. However, there was no care plan done which meant that the staff did not know what was required for transferring the resident. Some thought that she required the help of a sit-to-stand lift, others thought she was a two person assist, and still yet others thought that she was a one person assist with a gait belt.
On the day of the accident, she was being assisted from the toilet to her wheelchair by a newer aide. This aide thought that the resident required a sit-to-stand lift, but the lift was broken and she could not find anyone to help her transfer the resident, so attempted to do it herself. She got the resident up from the toilet and while the resident was in the process of pivoting, her legs gave out and she fell top the floor landing on top of her foot and ankle and breaking her ankle. The aide was not able to control her fall properly because she did not apply a gait belt to the resident, instead trying to hold onto her by her pants. Needless to say that did not work well, and the resident was taken to the hospital with a broken ankle.
There are three separate areas where the nursing home failed this resident, leading to this very preventable nursing home fall.
The first way is that there was no care plan which addressed what needed to be done to safely transfer a resident and prevent falls. When a resident is at risk for falling, a care plan needs to be put into place which is communicated to the staff and then carried out on a day-to-day, shift-to-shift basis. Without a care plan, patient safety is left to random chance. That is never acceptable.
The second way is the aide failed to use a gait belt. The whole point of having a gait belt is to control the resident during transfers and to arrest a fall should one occur. The aide (who in fairness, was relatively new) admitted that she forgot to use one. The consequences of not using the gait came home when this resident hit the floor and broke her ankle.
The third way is that the nursing home failed to devote appropriate resources to the care of its residents. The aide was not trained to use a gait belt. The fall prevention care plan was never put into place. There was not enough staff to help this aide. The lift was broken. These failures speak to a nursing home that is not spending the money that it required to properly care for its residents.
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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