IDPH has cited and fined Stonebridge Nursing & Rehabilitation nursing home in Benton after a resident there was rolled from bed, suffering a fractured leg which required surgical repair.
In the nursing home industry, the term “bed mobility” refers to the ability of a resident to change and maintain position in bed. When residents have deficits in bed mobility, it places them at increased risk for developing bed sores. Bed mobility is one of the areas which is assessed during the process of preparing the Minimum Data Set (MDS) and if the resident has deficits, they must provided assistance with one or two staff members. The level of assistance is recorded on the Minimum Data Set form and submitted to the federal government under penalties of perjury because the data submitted in the MDS forms part of the basis by which the nursing home is paid for the care it provides.
As a general rule, side rails are discouraged in the nursing home industry due to the risks associated with entrapment between the side rail and the mattress. There is also a risk of falls associated with residents trying to climb over the top of them. However, they may be used as a aid in bed mobility where the resident can use the upper rails to hold onto in changing and maintaining position in bed.
The resident involved in this nursing home fall suffered from a multitude of long-term conditions, including general weakness. She had been coded on her MDS form as requiring the assistance of two with bed mobility. She also had one upper side rail to assist with bed mobility.
On the day of this nursing home fall, a single nurse came into the room to provide care for skin breakdowns on the resident’s sacrum. The resident was positioned on her side, facing away from the one side rail that was in place to assist with bed mobility. The wheels to the bed were not locked in place. As the nurse went to get her supplies, the bed slid away from the wall and the resident rolled off the bed in between the wall and the bed, landing on the floor.
The resident had immediate pain in the left leg. An ambulance was called, and the resident was brought to the hospital where she was diagnosed with a comminuted fracture of the femur. She underwent surgery to repair the fracture.
There were at least four failures in the care that this resident received. First, she was repositioned in bed by a single staff member, rather then the two which were indicated by her MDS. Having one person do a two-person job is a well-recognized formula for disaster (see here, here, and here for examples). Second, the nurse left her unattended in a side-lying position, so there was actually no one available to help her maintain her position in bed. When two staff members are used to reposition a resident in bed, one is on each side of the bed to ensure that the resident does not continue rolling over the edge of the bed, such as happened here. Third, the resident was turned away from the side rail that was in place so that she had nothing to help her maintain her position in bed. Finally, the wheels to the bed were not locked in place. This in turn led to the bed rolling while the resident was in the side-lying position and contributing to her falling from bed.
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