IDPH has cited and fine Cedar Ridge Health & Rehabilitation Center nursing home in Lebanon after a resident suffered fractures to both legs in a fall from bed.
The resident at issue had an extensive medical history which included a below the knee amputation, morbid obesity, and a host of other medical issues. Her Minimum Data Set (MDS) reflected that she required the extensive assistance of two persons with transfers and bed mobility. The entry of that information on the MDS is significant because the MDS is completed under oath since it forms part of the basis of payment for the nursing home. The resident care plan also called for assist of two with bed mobility. The resident was regularly transferred with the use of a Hoyer lift, which requires two staff for safe operation.
On the day of this nursing home fall, the resident was getting ready to be transferred from bed to her wheelchair using the Hoyer lift. As part of the transfer process the sling of the lift had to be placed underneath the resident, requiring her to roll from side to side while the sling is positioned underneath her.
During the process of getting the sling positioned underneath her, the resident rolled to one side. Once the sling was positioned beneath her she rolled to the other side, but rolled off the edge of the bed, landing on her knees. She felt and heard a pop in both knees. X-rays showed that there were fractures to both femurs which required her to be transferred to a teaching hospital for further care.
We frequently write on this blog about mishaps that occur when you have one person doing a two person job, as that is often a formula for disaster (see here, here, here, here, and here for examples). Here it was unclear whether there was one or two staff people in the room at the time of the fall. The resident quite clearly described there being only a single aide involved. The aide claimed that there was agency staff in the room at the time but that the agency staff was not near the bed at the time of the fall. Whether there was one or two staff people on the room, if only one was involved in repositioning this resident, then the resident was not receiving the level of assistance required to keep her safe – a violation of federal regulations and a violation of the resident care plan.
While the care plan violations was most clearly the cause of this resident’s fall, there is potentially a deeper level to this: the understaffing of the nursing home. The resident related here that there would normally be only a single aide involved in getting her on to the sling for transfers even though two was required. When there is one person doing a two person job, that raises a fair question about understaffing. Sadly this is a feature and not a bug in 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:
Resident dies from brain bleed after fall at Elmwood Rehab in Maryville