IDPH has cited and fined River Bluff Nursing Home in Rockford after a resident there suffered a fractured elbow in a fall from her wheelchair.
For residents who are a fall risk, staying in a seated position is often the safest place to be. However, when a resident has poor trunk control as a result of weak core muscles, that is not always true. When a resident has poor trunk control, their torso can move well outside the center of the body, bringing their center of gravity forward or over to the side, resulting in them falling forward out of the chair or over the sides of the chair. To address this, a resident with poor trunk control may be seated in a chair or wheelchair that tilts backwards or with high arms to prevent falls.
This resident apparently had poor trunk control which was combined with a behavior of frequently bending forward to adjust the footrests on her wheelchair. Because of this behavior, part of her fall prevention care plan called for her to be seated in a tilted position in her wheelchair. However, due to poor maintenance of the wheelchair, she was not tilted back on the day of her fall. Further, the nurse on duty believed that since she was not demonstrating the behavior of bending forward to adjust the footrests it was not necessary to place her in a tilted position.
The net result? The nurse on duty left her in a regular seated position and then went to attend to other residents. After she did so, the resident leaned forward and fell out of her wheelchair. As a result of this nursing home fall, the resident suffered a broken elbow and a significant laceration to the head.
There are at least two issues with the care that this resident received. First, federal regulations provide that a resident receive care, treatment, and services necessary to prevent accidents, which includes falls. This includes making sure that the equipment that they use is well maintained and in good working order. Second, care plans are intended to be carried out on a day-to-day, shift-to-shift basis, and leaving the resident in a regular seated position when the care plan called for the resident to be tilted backwards was a violation of the care plan.
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