IDPH has cited and fined Presence St. Anne Center in Rockford after a resident there fell from a mechanical lift, suffered a broken neck, and died.
The resident at issue was dependent on staff to transfer him to and from bed with a mechanical lift. At this nursing home, the aides were provided with resident care cards which were located on the inside of the door. The care card called for an assist of two while transferring the resident with the mechanical lift.
On the morning of this nursing home fall, the resident was being transferred with a single aide. The resident slid from the sling and fell to the ground, hitting his head against the base of the lift. He was taken to the hospital where a CT scan showed that he had an unstable fracture at the C4-5 level.
The resident and his family elected to forego surgery and simply treat the fracture with a hard collar, knowing that further neurolgic complications could follow. The resident failed a swallow test, raising the risk that he could choke on his own saliva. He was intubated briefly to allow his son to return from out of the country, and after his son returned, the resident was extubated and placed on comfort measures only. He died three days after the fall.
When interviewed, the aide who was doing the transfer at the time of the fall stated that it was a busy morning and that she did not review the care card on the inside of the resident’s door. She further stated that the resident had been there as long as she had and that she was just doing as she was trained. The restorative nurse, who made the determination that an assist of two was required for mechanical lift transfers, told the surveyor that this was necessary because the resident suffered from contractures and that she would have never made him an assist of one with transfers.
The pattern which we see here is one which we see often with nursing home falls: doing a two-person job with only one person (see here, here, here, here, and here just as a few examples). There are at least three issues that are apparent with this particular unsafe transfer and the resulting injury and wrongful death of this nursing home resident:
- Understaffing – When interviewed, the aide described the morning of the fall as a busy morning and told the surveyor that she did what she was trained to do with regard to this resident. The fact that it was a “busy morning” raises the question of whether the aide rushed through the process of placing the resident in the sling to the lift because of the need to move on to the next resident. Past that, she told the surveyor that she did not read the care card, but did what she was trained to do, which raises the question as to whether this resident was routinely being transferred by a single aide when two were required, and if that was happening to him, how many other residents were/are being transferred in an unsafe manner?
- Training – A mechanical lift, used properly (and with enough staff) is a device which is suitable for accomplishing safe transfers. However, when the resident is not placed in the sling properly, a resident can very easily fall from the lift. This aide was attempting the transfer by herself which made proper placement of the resident in the lift all the more important. The fact of the fall raises fair questions about whether the aide knew how properly position the resident in the lift.
- System breakdown – There was a system in place at this nursing home to communicate the care needs of the resident: there was a card on the inside of the door stating what the needs were. All that had to be done was for the aide to review that. The aide admitted that she did not do so. Well-run businesses run on systems to ensure the delivery of the services that have to be provided day-in-day-out. When a system breaks down in such a spectacular fashion, wholesale retraining and enforcement of these basic systems is a necessity to prevent the same kinds of breakdowns and the same kinds of disastrous results from recurring.
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