IDPH has cited and fined Inverness Health & Rehabilitation nursing home after a resident there suffered multiple fractures in a fall due to violations of the resident care plan.
The resident care plan is one of the building blocks by which much of the routine care a resident in a nursing home requires is provided. Once a care plan is put into place, it falls the to the staff charged with carrying out the various steps in the care plan to actually implement the care plan on a day-to-day, shift-to-shift basis.
For the resident at issue, her Minimum Data Set (MDS) showed that she required the extensive assistance of two staff members with all transfers. This means that the resident required the hands-on help from two people to move from bed to wheelchair, wheelchair to chair or toilet, and so forth. The data in the MDS is certified under penalties of perjury to the federal government and the care needs shown on the MDS should be reflected in the resident care plan.
On the day of this nursing home fall, the resident was being transferred to the toilet by a single aide, not two staff members as called for by the resident care plan. Having one person do a two-person job is a formula for disaster, as we have written about many times on this blog (see here, here, here, here, and here for examples). In attempting to complete the transfer, the resident fell to the floor. As a result of the fall, the resident suffered fractures to the kneecap and to the tibia and fibula (the long bones of the lower leg) – but these injuries would not be discovered or treated for over a day.
When an aide is involved in a resident fall, it must be reported to the nurse so that the nurse can do an assessment on the resident. It then falls to the nurse to report the fall to the resident’s family and the resident’s doctor so that he can make orders about further care for the resident.
However, after this fall the aide simply helped the resident from the floor before reporting the fall to the nurse, exposing the resident to risk of injury from being moved when it was not safe to do so. Further the failure to report the nurse delayed the onset of care because nothing was done about the injuries until the following morning when the resident refused to get out of bed due to the pain she was experiencing.
The nursing staff then called the physician and the doctor’s physician’s assistant ordered STAT x-rays. The portable x-ray company advised that it could not make it the facility in a timely way, so the staff called the PA back and were advised to send the resident to the hospital. However, that did not actually happen for nearly 9.5 hours. Most nursing home staff members would agree that subjecting a resident to unnecessary pain is a form of nursing home abuse.
The immediate cause of the injuries to this resident was a violation of the resident care plan. The deeper question is why this occurred the way that it did. It likely relates to understaffing of the nursing home and the training of the staff. Having staff take dangerous shortcuts in the care of the resident (such as attempting a transfer with one when two are required) is a sign of an understaffed nursing home. Failing to invest in training of the staff so that the staff knows to follow the care plan and report falls when they occur is also something that reflects the choices that management makes regarding the nursing home. Sadly, understaffing the nursing home and failing to invest in the staff is consistent with the core features 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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