IDPH has cited and fined the LaSalle County Nursing Home in Ottawa after a resident fell from his wheelchair due to the absence of a slip-resistant cover for the seat cushion, and as a result suffered fractures to the elbow and hip.
Wheelchairs are one of the basic pieces of equipment in a nursing home and where you have a resident who is wheelchair-bound, there is more to using a wheelchair than just plopping them into the seat and pushing them where they need to go. The wheelchair must be properly maintained and have the right pieces accessories such as footrests, anti-tipping bars, and a proper cushion. Residents must still be repositioned within the chair every two hours at a minimum to provide pressure relief to prevent the development of bed sores. If the resident is going to be taken somewhere outside the nursing home in a van, the wheechair needs to be properly loaded and secured in the transport vehicle before the driver starts to pull away. Not having all of these things in place anytime the wheelchair is in use places the resident using it at risk for unncessary injury.
This nursing home fall was brought about by the failure to equip the wheelchair with a proper cushion. Wheelchair cushions besides providing pressure relief must be covered with a non-slip material to prevent the cusion with the resident on top of it from sliding forward out of their chairs and getting hurt as a result of the fall. The resident’s family bought a new cushion which was put into use right away. However, the cover with the non-slip surface on the bottom which was intended to keep the cushion from sliding out of the chair was not in use.
The usual practice when a new piece of equipment for a wheechair is put into use is that the therapy department evaluates it to ensure that the chair is still safe for use. That evaluation was never done – a crucial breakdown in the system.
As a result, the resident was leaning forward while brushing his teeth and the cushion slipped forward out of his wheelchair, causing the resident to fall to the floor. He suffered a broken hip and and elbow, and at 97 years of age, he is unlikely to recover fully from his injuries.
Well-run nursing homes operate on systems which make help ensure that routine items of care get delivered as required. When those systems are not actually implemented, then there are crucial breakdowns in the delivery of care such as this one which result in needless injuries to the resident. Here, there was a well-defined system of what was supposed to happen – therapy was supposed to check the cushion to make sure that it was safe to use. They would have recognized that the absence of the cover with the nonslip surface was a safety hazard and brought that to the attention of family and staff so that issue could have been corrected.
Past that, a more basic question is why was the family providing a wheelchair cushion to begin with. Federal regulations regarding nursing home falls require nursing homes to provides supervision and assistive devices necessary to prevent falls. In this context, the wheelchair cushion is as much an assistive device as the wheelchair itself. If the old cushion needed to be replaced because it was worn, soiled, or needed to be replaced for any other reason, it was the responsibility of the nursing home, not the family to provide that cushion.
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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