IDPH has cited and fined Symphony of Buffalo Grove nursing home after a resident there suffered multiple injuries in a fall from a lift that led to the resident being placed on hospice.
One commonly used piece of equipment in a nursing home setting is a mechanical lift, and used properly, it can be one of the most useful pieces of equipment in the nursing home. It allows the staff to easily move residents with significant mobility deficits from bed to wheelchair, wheelchair to chair, and so forth. Used properly, it minimizes the risk to residents and staff alike during manual transfers.
Of course like any piece of machinery, the risks of injury increase when it is not used properly. Proper use of a mechanical lift has at minimum three main parts: 1) the staff is properly trained in the use of the device, 2) the lift and all of its components parts and accessories are in good condition and used properly, and 3) two staff are used to complete the transfer – one to manage the controls to the lift, the other to supervise and assist the resident through the transfer.
Having one person doing a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples), and this event proved to be no different.
The resident involved had a long list of significant medical conditions, and had been declining since a hospital admission earlier in the year. She was dependent on staff for all care and required the assistance of two staff for all transfers, and her care plan called for use of a mechanical lift with two person assist for all transfers.
On the day of this nursing home fall, the resident was being transferred by a single aide from bed to her wheelchair so that she could receive assistance with eating lunch. The aide admitted to the state surveyor that she knew that there were supposed to be two staff members for all lifts but she did not get a second staff member to assist because they were busy due to it being lunch time.
When the aide went to get the resident up in the lift, she saw that there were six straps to the lift sling, not the four that the aide was accustomed to. She attached the sling to the lift just as she normally would have, ignoring the additional two straps that were a part of the sling. The aide then attempted to maneuver the lift into position, but as she did so, the resident’s foot bumped the arm rest of the wheelchair. The resident began to sway in the sling and then suddenly slid out of the sling onto the floor, landing feet first, but then hitting her head on the floor.
There was immediate bleeding from the back of the resident’s head. The aide got the nurse who tried to bring the bleeding under control and then called for an ambulance. The resident was brought to the hospital, where she was diagnosed with a brain bleed, a fractured skull, a fractured clavicle, and a fractured humerus. Surgery was not attempted and the resident was placed on hospice.
There are a number of causes of this very preventable injury. First the aide was not trained in the use of this lift and this sling, resulting in the sling not being attached to the lift properly. Second, the aide violated the resident care plan which called for two staff with all transfers via lift. Third, the aide attempted to transfer the resident on her own, not with the assistance of a second staff member as required by her training and the facility’s own policies. Had a second staff member been involved in the transfer, there is a reasonable chance that the sling would have been attached properly, but just as importantly, there would have been another staff member to help control the resident so that the contact with the wheelchair would have been avoided, as this is what led to the resident swaying in the sling and eventually being dumped from the lift onto the floor.
These are the obvious reasons for this fall, but there is a second level to this, and it relates to the overall management of the facility. The aide had not been properly trained in the use of the sling and the lift, and then proceeded with the transfer on her own because the staff was busy due to it being lunchtime. Being “too busy” to get the required number of people to provide proper care to a resident is a sign of an understaffed nursing home. Sadly, poor training and understaffing are a result 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.
Other blog posts of interest:
Fairhaven Christian Retirement Center resident dropped from lift, breaks hip
Addolorata Villa resident fractures hip in fall
Inverness Health & Rehab resident suffers multiple fractures in fall
Glenview Terrace resident suffers multiple fractures when lift topples over during transfer
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