IDPH has cited the Grove at the Lake nursing home in Zion after a resident there sustained a fractured ankle, an intracranial hemorrhage, and had her dialysis port ripped out when the sling failed while she was being transferred in a mechanical lift by a single aide.
This resident was dependent on staff to transfer her using a mechanical lift. It was well-established that this is an activity which required the assistance of two staff. The resident’s Minimum Data Set (MDS) and care plan called for the assistance of two staff with transfers. The facility policies and procedures also called for assist of two with transfers being done with a mechanical lift. Besides all of those reasons, it is good, safe nursing practice – having two people assist in a transfer using a mechanical lift allows one staff to control the lift itself while the other protects the resident during transfer. We have written many times about how having one person do a two-person job is a formula for disaster (see here, here, here, here, and here for examples).
On the day of this nursing home fall, the resident was being transferred to bed by a single aide using a mechanical lift. During the transfer, one of the loops that attached the sling to the lift itself failed, causing the resident to fall to the ground. As a result of this fall, she suffered a broken ankle, an intracranial hemorrhage, and had her dialysis port ripped out.
In the investigation, the aide involved reported that she had inspected the sling before use and attached the sling properly. The sling was sent to the manufacturer for analysis before it could be inspected by the state surveyor.
During the investigation, the aide acknowledged that the transfer was supposed to be done with two staff, but there were only two aide on duty that night and the other aide was too busy to help. She further acknowledged that she frequently transferred residents on her own – and the resident said as much when asked by the state surveyor.
One of the immediate causes of this fall was the fact that there was a single aide doing the transfer when two were required. However, there is a larger issue, and that is understaffing of the nursing home. When there are facts such having one person doing a two person job, that the staff present were “too busy” to help one another, and that the shortcuts in the care of residents were being routinely taken, these are signs of an understaffed nursing home.
Sadly, understaffing is a feature, not a bug in 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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