IDPH has cited and fined Westminster Village nursing home in Bloomington after a resident there sustained multiple fractures in a fall.
The resident involved was admitted for rehabilitation following a urinary tract infection and for age-related debility. However, less than 2 weeks after being admitted to the nursing home, the resident was discharged from physical therapy. The therapy discharge summary stated that the resident required stand by assist for all functional mobility due to decreased awareness of limitations. It also stated that the resident had limited potential for further gains and that resident would likely not achieve independent levels of function.
The resident was assessed as being at risk for falls and a fall prevention care plan was put into place. This called for assistance with activities of daily living and supervision with toileting and transfers. However, her Minimum Data Set showed a more extensive level of assistance being required: supervision with toileting, transfers, personal hygiene, and walking in her room.
On the night of this nursing home fall, the aide assigned to care for the resident set things up for the resident to get ready for bed including brushing her teeth. He left to attend to other residents because he believed that she was independent with those activities. He was unable to return for a while because other resident’s call lights were sounding.
After the resident got done brushing her teeth, she pushed the door to leave the bathroom and lost her balance, falling forward and hitting her face on the floor. She was complaining of chest pain, so she was sent to the hospital where she was diagnosed as having rib fractures, a fractured sternum, and multiple fractures of the jaw. The jaw fractures were significant enough that she required transfer to another hospital for a higher level of care.
There was a disconnect between what the resident needed and what the resident required in the way of care. The discharge summary from physical therapy called for the resident to get stand-by assist with all functional mobility, while the CNA assigned to the resident believed that she was independent. The care plan only called for supervision with activities of daily living. Clearly there was a breakdown in what was needed and was being provided. This resident needed someone in the room helping at the time of the accident, but did not get that help, and as a result sustained serious injuries in this fall.
The injuries that this resident sustained are significant above and beyond the pain which she experienced from the broken bones. Rib fractures and a fractured sternum make it difficult to inhale and exhale normally which can set the stage for developing pneumonia. The jaw fractures will result in decreased oral intake, which can set the stage for the resident to develop bed sores.
The fact that the aide was not able to return to the room in a timely fashion because of the needs of other residents raises a question of whether this is an understaffed nursing home. Unfortunately, not having enough staff on hand to meet the care needs of the residents is a common feature in the long-term care industry. 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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