IDPH has cited and fined Mason City Area Nursing Home after a resident there suffered a brain bleed due to a fall in which the resident was left unattended sitting at the edge of the bed after being transferred there by a single aide using a lift.
Safe use of a mechanical lift requires two staff people. One staff member will operate the lift while the other is responsible for the safety of the resident before, during, and following the transfer. We have written frequently about the predictable accidents that result when one person attempts to do a two-person job (see here, here, here, here, and here for examples).
The Minimum Data Set (MDS) is a part of the nursing home record where the results of various assessments of the resident’s abilities and needs are recorded. The MDS forms part of the basis by which the nursing home is paid, so it must be certified by the nursing home as being accurate. The last MDS completed with regard to this resident documented severe cognitive impairments and the need for extensive assistance with bed mobility and transfers. It further documented that the resident was not steady and only able to stabilize with staff assistance during surface to surface transfers and the need for extensive staff assistance during a lying to sitting on the side of the bed. These findings were largely consistent with the Discharge Summary completed by physical therapy when the resident was discharged from physical therapy four months before the fall having reached maximum potential. There, the resident was documented as not being able to achieve sitting balance. At the time of discharge the resident required total staff assistance with the use of a standing lift and was not expected to improve.
The resident was properly assessed as a fall risk and a fall prevention care plan was put into place. During the care planning process, there is an assessment of the risks to the health and well-being of the resident. There is then a series of steps that are put into place to address those risks which are assigned to the staff who then must implement the care plan on a day-to-day, shift-to-shift basis. Part of this resident’s fall prevention care plan included the use of a mechanical lift with assist of two staff for all transfers.
On the day of this nursing home fall, the resident was being transferred to bed using a standing mechanical lift with a single staff member assisting. The resident was brought to the edge of the bed, and as the aide went to move the lift away, the resident was left unattended sitting on the edge of the bed. The mattress that was in use on her bed was a low air loss mattress intended to help prevent bed sores, so it provided a less firm surface than a traditional mattress. While the aide was putting the lift away, the resident fell to the floor, hitting her head on the floor and cutting her head open.
After the fall, the resident was sent to the hospital to receive sutures. On her return to the nursing home, the staff recognized changes in her baseline mental status, and notified the attending physician who ordered the resident back to the hospital. At the hospital, a CT scan showed that there was a right-sided brain bleed. It was determined that the resident was not surgical candidate and over a 16 day admission to the hospital, her condition continued to decline, and she was discharged in the care of hospice. She died one month after the fall with the cause of death on her death certificate reading intracranial hemorrhage.
There are a number of causes of this nursing home fall. First, the staff failed to follow the care plan which called for two staff to assist with transfers using the lift. Not only is doing this consistent with the care plan, it is what basic industry safety practices require. Incredibly, not only did the staff fail to follow this, the also told the state surveyor that it was the staff’s discretion as to whether to use one or two staff for transfers. This shows poor training on the part of the staff. Secondly, the staff left her unattended at the edge of the bed when they should have known that she was not capable on maintaining that position.
The fact that this was a situation where you had one person doing a two person job is also an indicator that this was an understaffed nursing home. When you have staff that is taking shortcuts in the care of residents, this indicates that they do not have enough people on hand to meet the care needs of the residents. Sadly, this and failing to invest in the training if the staff is consistent with 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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