IDPH has cited and fined Park Place Christian Community nursing home in Elmhurst after a staff member there rolled a resident out of bed and onto the floor, resulting in the resident suffering fractures which led to the resident being placed on hospice.
“Bed mobility” in the long-term care industry refers to the ability of the resident to change and maintain position in bed. This includes things like being able to turn to the side and maintain that position. This is something that is important for having the staff provide incontinence care to help prevent the development of bed sores or to get a sling into position for transfers with a mechanical lift.
When residents have deficits in bed mobility, this is something that requires the assistance of staff. The extent of the resident’s deficits and the need for staff assistance should be recorded on the resident’s Minimum Data Set (MDS). The MDS is information which is submitted to the federal government and forms part of the basis by which the nursing home is reimbursed for providing care. Because of the financial implications of this, the data on the MDS is certified as being true and an accurate reflection of the care that the resident is in fact receiving.
This resident had a long medical history and was largely bedbound. Her MDS specified that she had deficits in bed mobility and required the assistance of two staff members with bed mobility. When two staff members are providing help with bed mobility and the resident is being positioned on her side, one should be positioned on each side of the bed. This way, when the resident is turned to one side, one staff member can do what is necessary (e.g., provide incontinence care, position the sling for the lift etc.) while the other assures the position of the resident on the bed and makes sure that the resident does not roll out of bed.
On the day of this nursing home fall, the aide was attempting to position the resident onto the sling for the lift. Even though this was designated on the MDS as a two-person assist, the aide was attempting to do this on her own. Having one person attempt a two-person job is a well-recognized formula for disaster (see here, here, and here for examples). Making the task all the more difficult, the resident was on a low-air loss mattress for the prevention of bed sores. This surface can make the mattress more slippery than it would be otherwise.
As the aide attempted to place the resident into the sling, she moved the resident’s legs away from her. The resident’s legs went over the edge of the bed, pulling the resident with her. The resident landed on her hands and knees. X-rays confirmed that she sustained fractures of the femur (the high bone) and the humerus (the bone of the upper arm). Rather than attempt surgery, the resident’s family elected to have the resident placed on hospice.
This was a highly preventable accident. All that it would have taken is for the resident to receive the care that the nursing home certified was necessary – two persons assisting with bed mobility. Had that been done, the resident’s legs would not have pulled her off the edge of the bed in the way that this happened and she would not have been injured and placement in hospice for necessary pain control would not have been required.
When staff takes shortcuts in the care that a resident needs – such as having one person doing a two-person job – this is an indication that the nursing home may be understaffed. Sadly, understaffing is a core component of the basic 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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