IDPH has cited and fined Heddington Oaks nursing home in Peoria after a resident there suffered a broken leg while being transferred from her bed to her wheelchair.
In this blog, we often focus on the care plan when nursing home residents suffer needless injuries. This is because the care plan is the road map for how routine care in the nursing home should be delivered. When there is a breakdown in the care planning process, this leads to poor care.
One area that we often do not focus on is the care plan itself. The care plan should reflect the needs of the resident as shown during the assessment and should be tailored to the needs of each resident and should be specific enough that the staff knows what needs to be done. However, when the care plan does not accurately reflect the needs of the resident, you can have the staff faithfully implementing the care plan, and the resident is still not getting the care he/she really needs. Such was the case here.
There is a document which nursing homes are required to prepare called the Minimum Data Set, or MDS. The MDS is submitted under oath to the federal government and is supposed to accurately reflect the care that the resident needs, based upon the assessment of the resident, the data that the staff compiles and upon interviews done by the MDS nurse with the staff. The reason that it is submitted under oath is that it forms part of the basis of how the nursing home is paid.
When the MDS is completed, the result of the MDS triggers a process known as the CAA, or Care Area Assessment which is a prompt for the care planning staff to develop a care plan in that area which should reflect the needs of the resident as shown during the assessment.
In this particular case, the resident’s MDS showed that the resident needed extensive assist of two staff members with transfers. However, as written, her care plan as written called for transfers to be done with moderate assist of one using a gait belt due to generalized weakness. Therefore, there was a mismatch between what the assessment said the resident needed (and what they certified to the federal government that they were doing) and what the care plan actually said.
One the day of this nursing home fall, the resident was being transferred from her bed to her wheelchair by a single aide who was using a gait belt. While the transfer was being performed, the resident reported that her legs were giving out. The aide used the gait belt to lower the resident to the floor, but in the process of doing so, one her legs went out to the side, and the resident suffered a fractured femur.
It is hard to fault the aide for this particular accident – she was doing what the care plan said she should be doing. The problem was that the care plan did not reflect what the true needs of this resident were. Bad care plans beget poor outcomes, and this is an example of that.
Sadly, this injury will probably have serious long term consequences for this resident, much as a hip fracture would. This resident will have an extended period of immobility due to the injury, and with her underlying conditions and issues, it will be hard for her to regain any real ability to ambulate again which will in turn set the stage for other issues such as pneumonia or bed sores.
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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