IDPH has cited and fined Michaelsen Health Center nursing home in Batavia after a resident there suffered a brain bleed after being rolled out of bed.
In the nursing home industry, the term “bed mobility” refers to the ability of a resident to change and maintain position in bed. Bed mobility is one of the areas which is assessed during the process of preparing the Minimum Data Set (MDS). The MDS form records the resident’s physical abilities and deficits and records the amount of assistance that a resident requires. The information on the MDS form is submitted to the federal government under penalties of perjury because that information forms part of the basis by which the nursing home is paid for the care it provides.
Beyond that the information gathered during the MDS process is often incorporated directly into the resident care plan. The care planning process has six steps: (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.
The resident at issue here had a cervical collar on due to a cervical spine fracture. She also had right-sided weakness which was a residual from having had a previous stroke. Her bed had a low air loss mattress, likely as a means of preventing bed sores.
On the day of this nursing home fall, the resident was receiving a bed bath from a single aide. The aide had the resident move onto her left side and cross her right leg over her body so that the aide could clean her back. At the time that was happening the aide was on the side of the bed where the resident was turning away from her. When the resident crossed her leg over her body, the momentum from that movement carried her leg over the edge of the bed. Due to her weakness from her stroke, the resident was not able to stop that momentum and this carried her over the edge of the bed. Because the aide was positioned such that the resident was moving away from her, the aide was unable to stop the fall as well. The resident crashed to the floor, hitting her head and leaving a bump on the back of the right side of her head.
The resident was brought to the hospital where a CT scan was performed which showed that she had a subdural hematoma of the left temporal lobe (the front front side of her brain). The doctor described this a contrecoup injury – a type of brain injury which occurs when the brain strikes the inside of the skull opposite the direction of a blow to the head. The resident was eventually returned to the facility where her care plan was upgraded to include assist of two with activities of bed mobility.
There were a number of shortcomings in the care of this resident. First, the aide turned the resident away from her so that the aide was in a position to stop the momentum which carried the resident over the edge of the bed. This is a fundamental skill which aides should have and exercise of this was necessary especially since the resident was on a low air loss mattress which can be a difficult support surface for bed mobility activities. Second, to the extent that the aide did not know that the resident should be turned toward her, this is an issue with staff training. Third, the care plan was revised upon the resident’s return to include two staff with bed mobility activities. An effective care planning process includes ongoing review of the effectiveness of the care plan and revision if it proves to be ineffective in practice. The fact that the care plan had to be revised after the fall suggests that a revision may have been required earlier but no critical thought was given to the actual care needs of this resident.
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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