IDPH has cited and fined Mar Ka Nursing Home in Mascoutah after a resident there broke both legs in a fall while being readied for a shower.
One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS. The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed. The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath. Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.
So, when the MDS states that a resident requires the assistance of two staff with transfers, that is telling the federal government that this resident requires the help of two staff members moving bed to wheelchair, wheelchair to chair, and so forth. When a resident requires extensive assist, that means that the staff must physically hold and support the resident during the transfer movement.
To do this safely, use of a gait belt is required. A gait belt is a sturdy canvas strap that is applied to the midsection of the resident. It provides the staff with a firm place to get a hold of a resident without trying to grab on to the resident’s body (many residents suffer from osteoporosis or brittle bone disease, which leaves the them susceptible to fractures from being grasped that way) or their clothing which is not designed for that kind of use and susceptible to tearing.
On the day of this nursing home fall, the resident was brought to the shower by a single aide. The aide was in the process of transferring the resident from her wheelchair to a shower chair and was undressing her. The aide was not using a gait belt. While she was doing this resident’s leg slipped on the wet floor. The aide could not control the resident and was lowered to the floor. There was an obvious deformity to one leg.
The resident was brought to the hospital where x-rays showed that there were fractures to the femur in both legs, with a fracture just above the resident’s prosthetic knee on the left side. The resident had to undergo surgery to repair both fractures. These injuries will have serious long term implications for the health and well-being of the resident, including by placing her at increased risk for developing bed sores or suffering pneumonia. Additionally it is unlikely that she will regain even her prior limited level of function after this injury.
There were a number of shortcoming in the care that this resident received which led to serious injuries with significant long term consequences for this resident. The resident was being transferred at the time of her injury by a single aide when two were required. Capping it off, that aide was not using a gait which was necessary to make the transfer safely. Finally, federal regulations require that the resident environment remain as free of accident hazards as possible. The loss of balance here was brought on by the slippery floor of the shower – a condition which could have been easily alleviated by the use of anti-skid strips on the floor of the shower.
When you have one person dong a two-person job it raises questions of understaffing of the nursing home. Unfortunately, failing to provide adequate staffing levels is a planned 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.
Other blog posts of interest:
Sling breaks during transfer at University Nursing & Rehab
Red Bud Regional Care staff fails to respond to call light, leading to fall
Broken ankle from fall at Aperion of Mascoutah
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.