The IDPH has cited the Mayfield Care Center in Chicago, IL, after a resident there fell off her bed and suffered a dislocated shoulder.
Fall was Due to Failure to Provide a Two-Person Assist
A two-person assist is often necessary to prevent residents from falling off their beds. While some residents just need one aide to help with their mobility, many others tend to roll on their bed away from the aide who’s trying to assist them. Thus, they need a second staff member to prevent them from falling off that other side.
In this case, one person from the nursing home staff did a two-person job. The resident had been assessed as in need of a two-person staff assist for her bed mobility. This meant that she had to have one staff member at each side of her bed to help her turn, reposition, and get up.
The resident was supposed to have two assisting staff members for bed mobility, but one of them reportedly had left the room to get towels. This momentary lapse in care caused the resident to roll and fall off the bed, dislocating her shoulder.
Care Plans Must Be Strictly Followed
It cannot be stressed enough that every resident’s care plan has to be implemented to the letter. The care planning process includes assessing the resident’s needs and planning specific steps to address those needs. These carefully planned steps have to be communicated to the nursing home staff, who must then follow them day by day, shift by shift.
This particular resident’s designation as needing two-person assist should not have been ignored or taken for granted. Her injury might have been avoided if the nursing home staff followed the care plan steps properly.
What’s worse is that improper implementation of the care plan happens too often in nursing homes, sometimes resulting in much more serious injuries. Over the last two years, we’ve written about residents who fell from their bed and sustained broken hips, severe fractures, and even brain bleeds. All that painful and costly suffering could have been avoided had the nursing homes fulfilled their duty.
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