IDPH has cited and fined Heritage of Mt. Sterling nursing home after a resident there suffered a broken leg in a fall which occurred due to the failure to use a gait belt while providing care and failing to provide care with two qualified staff members as required.
One useful tool in the care of nursing home residents is the Minimum Data Set (MDS). The MDS serves as repository of data regarding the abilities and care needs of nursing home residents. One unusual feature of the MDS is that the data contained on it is certified to the federal government as being accurate, as it forms part of the basis by which nursing homes are reimbursed for the care that they provide to residents.
This resident’s MDS included findings that she required extensive physical assistance of two staff with dressing, bed mobility, and transfers. During the care planning process, the resident was assessed as a fall risk due to a history of falls, poor cognition, and overestimating or forgetting her limitations. Her medical history also included a diagnosis of muscle weakness. The care plan called for two staff to assist with all transfers.
The nursing home also had standing policies which the staff was to follow in the care of residents. One of those was a policy regarding the use of gait belts. A gait belt is a woven strap that is applies around the midsection of residents while residents are receiving assistance with transfers or walking. It allows the staff member to better control the balance of the resident and either stop or slow down the rate of falls when the resident loses their balance.
On the day of this nursing home fall, the resident was seated on the edge of the bed while being dressed by an aide. There was no gait belt applied. The resident moved toward the edge of the bed to stand to transfer her from the bed to her wheelchair, but the resident’s legs gave out from underneath her, and she fell to the ground.
At the time of the fall, there was a second staff member called a unit assistant. However, that person was not trained to provide direct patient care to residents and was two feet away when the fall occurred. The administrator and director of nursing both told the state surveyor that a unit assistant did not qualify as a second staff person when the resident required the assistance of two staff with dressing and transfers.
The resident had immediate pain by the knee and was sent to the hospital where she was diagnosed as having a displaced periprosthetic fracture of the distal femur – meaning that there was a fracture of the thigh bone near the resident’s artificial knee where the two sides of the fracture were no longer in alignment. The team at the hospital elected against surgery, and the resident was placed in an immobilizer.
This injury will likely have significant impacts on the well-being of this resident, as her period of immobility will likely result in her no longer having even the limited ability to bear weight on the lower extremities. This in turn can set the stage for issues like the onset of pneumonia or the development of bed sores.
There are two obvious causes of this resident’s injury. One is the failure to use the gait belt as required by the facility’s own internal policies. The second is the failure to have two qualified staff people participating in the transfer as called for in the resident care plan – seeing as the unit assistant was not qualified to participate in helping with the transfer.
There is a deeper level to this, and it likely is that the nursing home was understaffed. When you see shortcuts being taken in the resident care such as not applying a gait belt or there not being two staff available when needed, these are signs of an understaffed nursing home. Sadly, understaffing is a part of 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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