IDPH has cited and fined The Spring at Monarch Landing nursing home in Naperville after a resident there suffered a broken leg during an unsafe transfer.
A resident care plan is intended to be a “road map” for the safe, proper delivery of the care that nursing home residents require on a day-to-day, shift-to-shift basis. It is the product of a multidisplinary assessment of the resident’s care needs. It identifies steps to be taken to assure the safety and well-being of the residents, and must be communicated to the staff who must implement the care plan on a day-to-day, shift-to-shift basis. Violation of the resident care plan is a violation of federal regulations and is a form of nursing home abuse because it subjects residents to unnecessary risk of injury.
The resident at issue here suffered from among other things Parkinson’s Disease and Alzheimer’s. She had been assessed per the Minimum Data Set as requiring the assistance of two for transfers and her care plan called for the use of a mechanical lift to transfer the resident. At this nursing home, one way that the content of the care plan was communicated to staff was through care cards that were located in the resident’s closet.
On the day of this nursing home fall, a single aide attempted to transfer the resident from bed to a wheelchair to bring her to breakfast. No gait belt was used at all, and in the process of attempting the transfer, the resident’s legs gave out and she was lowered to the floor by the aide. The aide then called for the help of a second aide to get the resident from the floor (even though she should have been assessed first by a nurse) to her wheelchair and then taken to breakfast.
The aide did report the fall to a nurse who said that no incident report was required because no fall occurred. The nurse was wrong about this – in the long term care industry, a fall is generally defined as an unplanned change in elevation. The “lowering to the floor” of this resident by an aide qualifies as a fall. Because the nurse wrongly considered the incident to not be a fall, the doctor was not notified and the later shift was not told about the incident. As a result, there was a lengthy delay in obtaining care for this resident.
During a later shift that day, the resident was complaining of pain to the leg. A nurse readily saw that one leg was larger than the other, and notified the resident’s doctor who ordered a stat x-ray of the leg. This showed a fractured femur, and the order was given to send the resident to the hospital.
There are a number of problems with the care that this resident received. To start with, a mechanical lift wasn’t used, as was called for in the resident care plan. If a lift was used, this fall would never have happened. Past that, the aide attempted the transfer alone, rather than with the help of a second staff member as was necessary. The aide also failed to use a gait belt which may have helped her in arresting the fall before the resident ended up on the floor. A cascade of failures resulted in this resident’s broken leg.
The failures continued after the resident’s fall. The aides moved her on their own without getting a nurse in to assess her for injury. They did report the fall, but the nurse failed to recognize it as such and failed to advise the resident’s doctor or advise the later shifts that the fall had occurred. This means that the resident was left with an untreated broken leg for hours before the injury was finally recognized.
This series of failures is a snapshot of a facility which is not properly training its staff. Failing to invest in staff training is a feature 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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