IDPH cited and fined the Grove of Skokie nursing home after a resident there suffered a broken leg due to an unsafe transfer which was also a violation of the resident’s care plan.
The basic purpose of a care plan is to outline a series of steps that the nursing home staff can take on a day-to-day, shift-to-shift basis to reduce the risks of harm to the resident. The nursing home staff will almost always agree when asked that it is part of their job to implement the care plan.
The resident at issue here suffered from multiple sclerosis and as a result had significant mobility deficits. Therefore, her care plan called for the assist of two staff and the use of a mechanical lift for all transfers – meaning that any time she was being moved from bed to wheelchair or wheelchair to chair and so forth that two staff members would use a mechanical lift to accomplish the transfer.
On the day of the injury, the resident was getting a shower and needed to be transferred from her wheelchair to the shower chair. Rather than use the mechanical lift as called for in the care plan, two aides attempted to transfer the resident to the shower chair with a two person manual transfer. During the transfer, the resident was not able to continue to bear any portion of her own weight and the staff lowered her to the floor.
When a nursing home chart describes a resident being “lowered to the floor,” that is actually a nursing home fall. A fall is generally considered to have occurred when there is an unplanned change in the vertical level of the resident. And despite the benign description of being “lowered to the floor,” this is something that can and frequently does produce injury to the resident.
Following this incident the resident began to complain of leg pain. X-rays showed that the resident suffered a comminuted fracture of the leg, meaning that it was broken in multiple places.
Here, the resident’s injury was clearly produced by the violation of the care plan. The care plan was in place to prevent just this kind of injury, but the staff chose to not follow it, and a very predictable and preventable injury was the result.
The violation of the resident care plan was the obvious cause of the resident’s injury, but a deeper look at the circumstances surrounding this injury raises questions as to whether this was an understaffed nursing home. Use of the mechanical lift was called for by the resident care plan, but the staff chose to not follow it, likely because it would have taken more time than attempting the manual transfer. Any time you see information which indicates that the staff is taking shortcuts which sacrifice resident safety, understaffing should be a consideration.
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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