IDPH has cited and fined the Pearl of Rolling Meadows nursing home after a resident suffered a broken hip as a result of an unsafe transfer while being transferred to the toilet.
The resident at issue had weakness and limitations in range of motion such that she could not fully bear weight on her lower extremities. She was assessed as requiring the assist of two for transfers between surfaces. As part of her care plan, the staff was to use a sit-to-stand lift to move her to the toilet. The resident care plan called for the use of two aides to make a safe transfer using the sit to stand lift, as did the nursing home’s own internal policies and procedures. The facility policy and the manufacturer’s specifications both called for the use of two buckles to adequately support the resident in the sling while being transported.
On the day of the accident, the resident was being transferred to the toilet by an aide. The resident told the aide that transfers were normally done with one person. The aide placed the resident in the lift, but was only able to secure one of the two buckles to the sling. The aide brought the resident to the bathroom, but due to the small size of the bathroom, had difficulty positioning the resident over the toilet. The resident believed that she was over the toilet and let go of the lift. She was not actually over the toilet and crashed to the floor, suffering a broken hip.
This was a highly preventable accident with serious consequences for this resident. There were multiple failures on the part of the aide which led to this nursing home fall: failing to follow the care plan, failing to follow facility policies and procedures, failing to secure the resident in the lift properly, and failing to properly position the lift over the toilet. Curing any one of these failures probably would have avoided this injury, but would not have cured the fact that this was substandard nursing home care all the way through. One of the things that we believe in our law firm is that bad care is often provided in nursing homes, and the fact that nothing bad happens is often the result of being lucky. Being lucky is not a substitute for good care because you never know when the gamble you take with a resident’s safety is going to come back to bite you.
A hip fracture is a serious injury for a person who is in the typical age range for nursing home residents. Many have significant pre-existing health issues which make undergoing surgery for repair of a hip fracture a risky proposition indeed. Assuming that they survive the surgery and immediate post-operative period, many do poorly following surgery for repair of a hip fracture, both in terms of quality of life and in terms of life expectancy. Any death that is caused in whole or in part by a nursing home fall which results in hip fracture can be the basis for a wrongful death lawsuit.
An additional issue came to my attention while reading this citation, and that was this: the resident said that the transfer was normally done with only one person. The aide then went ahead and did the transfer with only one. Even though the care plan and facility policies called for two persons to assist in this kind of transfer, the aide proceeded with one. Why did the resident think that only one person was needed? Why did the aide proceed with the transfer one her own with only one person in the face of flashing red lights that said that two people were needed? The likely answer to that is that both the resident and the aide both knew that there really wasn’t enough help on hand to use two people, and that speaks to an issue of understaffing at this nursing home home.
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