IDPH has cited and fined Gardenview Manor nursing home in Danville after a resident there suffered a fractured hip due to unsafe technique being used during a transfer with a mechanical lift.
Mechanical lifts are frequently used in nursing homes, and used properly, they can be a tremendous benefit to both residents and staff. For residents, it offers a safe, relatively comfortable way of being moved from bed to chair and so forth. For staff, it greatly reduces the risk of suffering injuries to their backs, shoulder, and knees from the physical strain of trying to physically lift a resident from place to place. However, the key to this is “used properly” – as we have seen many instances where residents were badly injured as a result of one staff member attempting to transfer the resident alone instead of with two people as is required (see here, here, here, and here for examples).
For the staff to use the mechanical lift properly, they must be trained in the use of the lift. Most nursing homes have training programs for staff to develop competency in using the lift. At a minimum, this should include information which tracks the instructions for use in the owner’s manual or operations manual from the manufacturer. Having staff not properly trained in the use of the lift is a formula for disaster.
The resident at issue was dependent on use a mechanical lift for transfers. On the day of the accident, there were in fact two staff on hand to complete the transfer. When two staff are being used (as should always be the case), one staff member has the responsibility of operating the controls while the other steadies the resident in the sling during the transfer. The staff loaded the resident into the sling, and began the transfer. As the resident was suspended in the air, the aide assigned to steady her had to move some bags out of the way of the path of the lift. As she did so, the resident began to rock in the sling, leading the sling to topple over, causing the resident to hit the floor and suffer a fractured hip.
The investigation into this fall revealed a number of causes of this nursing home fall. First, the resident’s both of the resident’s legs were positioned on one side of the lift mast. This resulted in the resident’s weight being distributed on one side of the lift which reduced the stability of the lift. Second, the resident was not lowered after being lifted from the bed. A lower center of gravity also promotes stability during transfers. Third, the legs to lift were not in the widest position which reduced the width of the base of the lift. These three factors – weight distributed to one side, a high center of gravity, and a narrow base – placed the lift at risk of toppling over.
The last factor that led to the fall is that the aide on the sling had to let go of the resident during the transfer to clear bags out of the way. One basic part of every fall prevention care plan is to keep floors and walkways clear of clutter and debris. The overwhelming likelihood is that even with the bad technique being employed during the lift, this could have been accomplished without incident (which is different form being done safely) had the aide not had to clear things out of the way.
The poor technique used is the fruit of poor training of the staff. Indeed when the state surveyor asked for records showing that the staff had training on the proper use of the lift, the administrator was unable to produce any. Failing to invest in proper training of the staff is one way that nursing home ownership fattens its bottom line. Sadly, poor training of the staff leads to poor care and poor outcomes.
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.
Other blog posts of interest:
Resident suffers fatal brain bleed in fall at Pleasant Meadows Senior Living in Chrisman
Danville Care Center cited for unsafe transfer
Critical medication error at Gardenview Manor
Fall results in fractured kneecap at Country Heath in Gifford
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