IDPH has cited and fined the Grove of St. Charles nursing home after a resident there suffered a fractured hip due to being rolled out of bed while receiving incontinence care.
The resident involved suffered from incontinence of bowel and bladder. Her Minimum Data Set (MDS) showed that she required the assistance of two staff members with bed mobility (turning from side to side and changing and holding positions in bed) and her care plan called for the assistance of two staff members with incontinence care.
One the day of this nursing home fall, the resident was in bed on a low air loss mattress. She was receiving peri care after an episode of incontinence. There was a single aide who was providing the incontinence care. As the resident’s leg was moved over across her body, the leg went over the edge of the bed and the resident followed, landing on her knees.
She was brought to the hospital where a hip fracture was diagnosed. However, even though the nature of the fracture likely warranted it, the decision was made to not proceed with surgery because of her pre-injury lack of mobility, her risk factors, and other medical issues. She now has to be transferred using a lift. In the meantime, she has unstable hip which is subject to movement during transfers with the lift, while being turned and repositioned to prevent bed sores, and while receiving incontinence care.
This a tale that we have told many times about the results you get when you have one person doing a two-person job (see here, here, and here for examples). When two people are required to assist with bed mobility, the purpose of the second staff member (the one not providing the incontinence care) is to provide safety and help prevent the resident from falling out of bed. This is especially necessary where the resident is on a low air loss mattress because they tend to provide less friction and resistance and make it easier for the resident to slide out of bed.
This is a simple case of a staff member violating the resident care plan and taking a short-cut in providing care to the resident. The deeper question of course is why did she feel compelled to provide care to the resident on her own when two were required? The answer likely lies in short-staffing of the nursing home. Unfortunately, understaffing is a feature and 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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