IDPH has cited and fined Prairie Manor Nursing & Rehabilitation Center in Chicago Heights after a resident there suffered a brain bleed due to being rolled out of bed while receiving incontinence care from a single staff member rather than the two that were needed.
In the long term care industry, the term “bed mobility” refers to the ability of the resident to change and maintain position in bed. This is an important area for assessing a resident’s abilities because the resident’s ability to change positions in bed is crucial for things like incontinence care and turning and repositioning, all of which are important for the prevention of bed sores.
The resident’s abilities with regard to bed mobility are recorded on the Minimum Data Set (MDS) which is a document which is submitted under oath to the federal government and is part of the basis for calculating the payments to the nursing home for the care that the resident receives. When the MDS indicates that a resident requires extensive assist of two staff members for bed mobility, this indicates that the resident has little to no ability to change or maintain position in bed. When two staff are providing care in bed to the resident, one staff member should be on each side of the bed with the staff member on the side of the bed in which the resident is turning being charged with making sure that the resident does not fall from the bed. To assist the staff in knowing which residents require the assistance of two staff, the staff is provided with a care card which spells out the requirements for care of that resident.
On the day of this nursing home fall, the resident was receiving incontinence care from a single aide. As the aide turned resident away from her, the resident slid off the edge of the bed, hitting her head on the floor. She had immediate bleeding and was sent to the hospital where scan showed that she suffered a brain bleed.
Besides this being a situation where you had one person doing a two-person job – which is almost always a formula for disaster (see here, here, here, here, and here for examples), the aide compounded the problem by rolling the resident away from her instead of bringing her toward her while positioning the resident.
The deeper question is of course why did this aide attempt to do a two-person job by herself? The likely answer relates to understaffing of the nursing home. The aide explained to the supervising nurse that she could not find anyone to help her. Not having staff available to meet the care needs of the resident is characteristic of an understaffed nursing home. Unfortunately, understaffing of the nursing home is a feature, and not a bug, in the nursing home business model. The net effect of understaffing is that it doesn’t give the staff the ability to provide proper care for the residents – and the net result of that is unnecessary injuries such as this one.
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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