IDPH cited and fined Piatt County Nursing Home in Monticello after a resident there fell from a power recliner chair and suffered fractures to her neck, leading to placement in hospice.
Any piece of equipment used in the care of nursing home residents must be safe for use with that particular resident, and it is upon the staff to make assessments as to whether that piece of equipment is safe for use. If the equipment is not safe or could not be made safe through adjustments to the equipment, education of the resident, or close supervision of the resident, then the equipment should not be put into use.
That of course assumes that the assessment of the safety and appropriateness of the equipment is made. This incident is about what happens when a proper assessment is not made.
The equipment at issue is a chair known as a power recliner. It is a chair which tilts backward like a regular recliner, but is useful for people who have a hard time getting up from a seat because it tilts forward and boosts the back upwards to make it easier for the user to get up from a standing position. The chair moves from a reclined (tilted back) to a tilted forward position with a power control which can be operated by the user.
The power recliner had been in use at the nursing home for a long time – to the point that they no longer had the owner’s/operations manual. During the investigation into this incident, the IDPH representative contacted the manufacturer who advised that they had stopped manufacture of this particular chair in 2007. However, the manufacturer had advised that in order to use the chair safely the resident had to have the ability to bear weight independently and be alert enough with the cognitive ability to safely use the chair.
The resident involved in this incident had a history of stroke with residual left-sided weakness. Those impairments were significant enough that she required the use of a mechanical lift for transfers. She had been assessed as having moderate cognitive impairments.
On the night of this nursing home fall, the resident had been dangling her foot over the edge of her bed and telling the staff that she needed to leave to go somewhere. The staff transferred her with a lift to the recliner. At some point during the night, the resident used the remote to lower the chair and then bring it forward so that she was in a position where she was tilted forward.
As she reached that position, she fell forward, hitting her face on the floor. There was immediate obvious bleeding, so she was sent to the hospital. There she was diagnosed as having fractures of the C1 and C2 vertebra. After a brief hospital admission, she was returned to the nursing home under the care of hospice. The
This was a case where the proper assessments were not made for the resident to use this equipment. She had demonstrated, known cognitive impairments, known musculoskeletal deficits, and was not able to bear weight well enough to participate in regular transfers. She did not meet any of the standards for use given the manufacturer’s recommendations for the use of this equipment. Past that, the resident had been verbalizing a desire to go elsewhere. As with residents who elope from the nursing home, her expressed desire to go elsewhere was a sign that she was likely to try to get up unassisted, and the use of this chair made that all the more hazardous. Very simply, this was a resident for whom use of this equipment was not suitable as a general proposition, but especially that night. The net result – catastrophic yet preventable injuries for this resident.
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