IDPH has cited and fined Southpoint Nursing & Rehab nursing home in Chicago after a resident there suffered a broken leg as a result of an improper transfer.
The Minimum Data Set (MDS) is a report which is submitted under oath to the federal government and describes the level of care that a resident is receiving. It is supposed to be based upon the information in the resident chart, discussions with staff members and the resident and family, and on the assessment of the individuals signing off on it.
The reason that the MDS is completed under oath per federal regulations is that the response in the MDS can change the acuity level for the resident which in turn can affect the payment that the nursing home receives for caring for the resident. In short, there is money involved, so honest reporting on the MDS is required.
The responses on the MDS in turn trigger something called a Care Area Assessment (CAA) which is an indication to the care planning staff that particular areas should be considered in the care planning process. This helps assure that the resident is receiving the care he or she needs on a day-to-day basis.
The resident at issue was coded on the MDS as requiring extensive assistance with transfers and bed mobility from two staff members. She was totally dependent on staff members for activities of daily living. Given that was how she was coded, per facility policies, this should have been reflected in the care plan and in the care that the resident was receiving on a day-to-day, shift-to-shift basis.
On the day of this nursing home fall, the resident was being transferred from her bed to a wheelchair by a single aide using a gait belt. The resident’s leg buckled and the aide was forced to lower her to the edge of the wheelchair and then after obtaining some additional help, to lower her to the floor. The resident was brought to the hospital where x-rays showed that she had a broken femur. She underwent surgery to repair the fracture.
At first blush, this appears to be a common case of one person doing a two-person job, as we have often discussed on this blog (see here, here, for examples). While this is true, it is also not the whole story.
When the state surveyor interviewed the staff at the facility, the aide explained that she regularly cared for the resident and knew that the resident was a one-person transfer because there was a note above the resident’s bed that said “B-1” which meant that the resident was a one-person transfer. The surveyor then went and interviewed the floor nurse, who is supposed to be supervising the aide, and the nurse told her she followed along with what the aides told her because they know what to do for each resident. Finally, the surveyor was told by the restorative nurse that “B-1” meant one person assist for bed mobility – which is of course not what the MDS indicated.
To summarize: the MDS and the care plan called for two-person extensive assist with transfers. The aide charged with providing that care had not been providing that care as a matter of routine because she misunderstood the significance of the sign over the resident’s bed. That sign did not even track the level of care that the resident was supposed to receive. Topping it all off, the nurse who was supposed to be supervising the aide simply relied on the aide to know what to do – an assumption that was not borne out by what was happening all around her.
Having this many levels of breakdowns in care might be called a comedy of errors – if it were not for the fact that a resident suffered a significant injury which will likely have longer term consequences which will place her at risk of a premature death.
Sadly, having a staff that has not been properly trained and having a nursing home claiming to be providing a higher level of care than is actually being delivered is all too typically a part of the nursing home business model. 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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