The resident had severe cognitive impairments and required the assistance of two for bathing due to generalized weakness and immobility. However, even though she required that level of assistance, that was not incorporated into her care plan.
On the day of the fall, the resident was brought to the shower room, transferred to the shower bed and was being showered with a single aide. The aide turned his back after providing pericare to the resident and as he did so, the shower bed tipped over and the resident fell forward lading on her face. She was taken to the hospital where testing showed multiple painful facial fractures and a dislocated jaw.
This is a simple case where there was a clear breakdown in the care planning process. This is a resident who was assessed as requiring assist of two with bathing. The next step in the care planning process is to incorporate the care needs of the resident into the care plan. That was not done, so even though the aide claimed to have reviewed the care plan, it didn’t tell him that two were required for bathing the resident.
Incorporating that into the care plan was something that was clearly necessary as has been the case in several other incidents we have covered in our blog – here, here, and here, for instance – where the resident was rolled out of bed when a single aide was providing care to the resident with one rather than the two that was called for in the care plan. The reason for this is that the resident has so little control over their body that they are at high risk for falling from the bed when moved onto a side-lying position. I also recognized that the aide apparently accomplished the transfer of the resident to the showed bed using a mechanical lift by himself – something that has come to grief as often as not, such as was seen here, here, and here.
Obviously, there was a clear issue going on that led to this fall relating to the breakdown in the care planning process, but the fact that there was also a transfer with the lift accomplished speaks to possible issues relating to staff training and understaffing. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of 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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