IDPH has cited and fined Hilltop Skilled Nursing & Rehabilitation Center nursing home in Charleston after a resident there suffered a broken leg in a fall from bed.
The resident at issue had a complex medical history which included paraplegia, a right arm contracture, and a Stage 4 pressure ulcer to the buttock and another bed sore to the sacrum. After a nursing home resident develops a bed sore, federal regulations require the nursing home to provide care, treatment, and services to promote healing, prevent infection, and prevent the development of new pressure ulcers. Here, as part of the wound care strategy, there was an order in place for the use of a low-air loss mattress.
One of the main risk factors for the development of bed sores is pressure (part of why they are called pressure ulcers). Pressure is also an impediment to wound healing. A low-air loss mattress helps to prevent bed sores and aid in the healing of existing ones by reducing pressure. One of the downsides of the use of a low-air loss mattress is that it is harder to maintain a safe position in bed because of the way that the mattress supports the body. This is especially true with resident who have impaired mobility, as was the case with this resident who suffered from paraplegia and had an upper extremity contracture. These mobility impairments were recognized in advance of this nursing home fall as the resident’s Minimum Data Set showed that the resident required the assist of two staff with bed mobility and transfers.
Further, even before the fall occurred, the staff was aware that the resident had difficulty maintaining her position in bed as the staff would find that she had slid down to the bottom of the bed or at other times found that she had her feet hanging over the edge of the bed.
This situation – the use of an air mattress with a resident who had known impairments to bed mobility and who had demonstrated recurrent problems with safe positioning in bed – presented a picture where the resident was at risk of falls, specifically sliding out of bed and being injured. When there is a risk of a resident experiencing a fall, then a fall prevention care plan must be put into place. Unfortunately, despite the need for a care plan to address this risk of injury to the resident, nothing was done. During IDPH’s investigation, the administrator admitted that the care plan should have been updated to include monitoring the resident’s position in bed and that the resident’s injury was their fault.
On the morning of this nursing home fall, the resident was discovered on the floor at about 6 am by the staff. She told the staff that she slid out of bed. The resident was complaining of pain, but the staff failed to notify the resident’s physician, but instead called to have a portable x-ray service come in. The x-rays were no performed until the early evening. The results from the radiologist who read the films did not come in until nearly 9 pm. The x-rays showed a fracture of the lower part of the femur. At this point, the resident’s physician was notified and he ordered the resident sent to the hospital.
Besides the resident experiencing an unnecessary fall, this resident was also subjected to experiencing prolonged unnecessary pain by the failure of the staff to timely notify the doctor. The doctor told the state surveyor that had he been made aware of the situation, he would have sent the resident to the emergency room earlier. Most nursing staff will agree when asked that subjecting a resident to unnecessary pain is a form of nursing home abuse.
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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