IDPH has cited and fined University Rehab nursing home in Urbana after a resident there suffered a fractured hip in a fall from bed while he was receiving incontinence care.
Doing proper assessments is a basic step to assuring the safety of nursing home residents. Two assessments which are done in well-run nursing homes are bed mobility assessments and side rail assessments. Bed mobility refers to the ability of a nursing home resident to turn, change position, and maintain position in bed. This is important because it helps determine the staff levels and equipment needed to provide proper care to a resident while they are in bed. It is one of the assessments recorded in the Minimum Data Set (MDS) for a resident. Side rails carry some risk of injury or entrapment, and the side rail assessment is used to determine whether the use of a side rail as an aid in bed mobility and/or transfers warrants the risk associated with the use of the side rail.
The resident involved had been a resident at the nursing home, but was relatively new to the room where the incident occurred. In his prior room, the bed was equipped with a side rail. However, in his new room, the bed in his new room did not have side rails.
On the day of this nursing home fall, he was receiving incontinence care form an aide and was positioned on his side, bracing himself with his arm against the wall. The aide removed the brief and was placing a new brief underneath him. As she did so, he rolled out of the bed, suffering a fractured hip which required surgical repair.
When he was in his prior room with the bed with the side rails, he would use the side rails to maintain position while receiving incontinence care. Facility policies called for continuing all interventions which had proven successful in preventing falls. The practice at that nursing home had been to move a resident’s bed with them when they were moved to a new room. This was not done, and the resident was provided with a bed that had no side rails. Had the resident been provided a bed with side rails, he would not have had to be positioned as close to the edge of the bed to reach the wall and would not have had so much weight hanging off the edge of the bed, placing him at greater risk for falling from bed.
Further, investigation showed that there were no assessments of the resident’s bed mobility or side rail assessments in the resident’s chart. Had these been done, it is likely this resident’s care plan would have called for assistance of two staff during incontinence care or the use of side rails for assistance with bed mobility. Either of these steps would have likely prevented this fall and injury.
There were a number of breakdowns in the care of this resident which led to the fall and broken hip. First, there was the lack of proper assessments which led to issues relating to bed mobility not being addressed in the resident care plan. Second, the facility policy of continuing effective fall prevention measures was not followed in that side rails were not incorporated when the resident changed rooms. Finally, the practice of moving the bed with the resident was not followed. Any one of these would likely have prevented the injury to this resident.
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