IDPH has cited and fined Michaelsen Health Center nursing home in Batavia after a resident there experienced a fall which led to a hip fracture and the death of the resident.
In providing care for nursing home residents, there are certain fundamentals which must be followed to prevent nursing home falls. One example of this is using two staff members for mechanical lift transfers (see here, here, and here for examples of what happens when this doesn’t happen).
One of those other fundamentals is the use of a gait belt when performing a resident transfer where the resident needs assistance with transfers. A transfer is moving a resident from one place to another, such as from bed to a wheelchair or a wheelchair to a chair. A gait belt is a canvas strap that is applied around the midsection of a resident during transfers to help control the resident and if a fall occurs, to arrest or slow the fall in order to reduce the chances of serious injury.
The injury suffered by this resident was exactly the kind of injury which is likely to result when there is a failure to use a gait belt during a transfer.
This resident was being transferred from a wheelchair to the shower chair in preparation for being showered. To get the resident from the wheelchair to the shower chair, a pivot transfer technique was used. Usually, this entails placing the wheelchair at a 90 degree angle to the bed or chair that the resident is being transferred to or from. The resident is then assisted from the original surface and pivoted over to the new one (hence the name “pivot transfer”). A gait belt is necessary for this kind of transfer to assure the safety of the resident while rising, while pivoting, and then assuring the proper positioning and safety of the resident on the new surface.
During this transfer, the wheelchair was placed facing the shower chair, requiring more movement on the part of the resident. No gait belt was used. The shower chair was also very high for the resident, making it difficult for her to get seated on it properly. As a result of the all of the above, when she was seated on the shower chair, she was not on it squarely, and and in scooting herself to get seated on it properly, she went off the edge of the seat and fell to the floor, landing on her hip.
She was brought to the emergency room where she was diagnosed with a hip fracture. She underwent surgery the next day. The citation includes information from the coroner relating to the fall and the hip fracture but doesn’t spell out exactly what happened after undergoing surgery. One of the reasons that hip fractures are such an important issue in the long term care industry is that many nursing home residents suffer complications either during or immediately following surgery to repair hip fractures which results in the death of the resident.
There were a number of breakdowns in the fundamentals here, in particular the failure to use the gait belt. Using a gait belt here would have helped the resident get on the shower chair properly, helped her safely adjust her position, and potentially have slowed her fall and avoided the fractured hip. Prevention of this kind of fall is exactly what use of a gait belt is a must.
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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