IDPH has cited and fined Havana Health Care Center nursing home after a resident there suffered a broken shoulder due to being mishandled by staff while she was repositioned in bed.
“Bed mobility” refers to the ability of a resident to change and maintain their position in bed. When a resident has deficits in bed mobility, it is up to the nursing staff to help change their position in bed. When a resident needs to be moved toward the head or the foot of the bed, a lift sheet is used to help reposition the resident.
A lift sheet is laid on top of the fitted sheet and staff lifts the resident up part way and moves them up and down in bed. Besides being helpful in repositioning the resident, the use of a lift sheet reduces the amount of friction and shear to the resident’s skin, something that increases the risk of developing bed sores. Use of a lift sheet in repositioning residents was called for in the nursing home’s policies and procedures.
The resident at issue had a medical history which included chronic lower back pain and a stroke with residual right-sided weakness. Her Minimum Data Set (MDS) certified that she required extensive assistance of staff with bed mobility.
On the day of this resident’s injury, the lift sheet was underneath the resident in a position where the staff could not easily access it. Because it was a busy time with a lot of call lights going off, the aides decided to lift the resident from under her armpits. As they did so, there was a pop heard coming from the resident’s shoulder and she had immediate pain. However, it was not until the next shift that a nurse notified the doctor. An order was placed for an x-ray which showed that she had a fracture of the proximal humerus (the portion of the upper arm which inserts into the shoulder socket).
The treating orthopaedic surgeon confirmed for the state surveyor that this kind of fracture is “a very painful injury, especially initially.” The resident’s physician ordered Norco the following day. However, the resident did not receive the medication due to the nursing home failing to obtain the necessary authorizations for the pharmacy to release a controlled substance, resulting in the resident experiencing unnecessary pain.
There are a number of issues with the care that this resident received. The first level relates to the mishandling of this resident. Use of a lift sheet was called for by facility policies and procedures, but the staff instead mishandled the resident, resulting in the injury. Second, once the injury occurred, she did not receive the prescribed pain medication, resulting in her experiencing unnecessary pain.
These are of course the superficial reasons why. The deeper reason is likely understaffing of the nursing home. This is shown by the fact that the staff took shortcuts in the care of this resident because it was so busy – a sign that there are not enough hands on deck to meet the care needs of the residents. Sadly, understaffing is a core feature 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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