IDPH has cited and fined University Rehab Northmoor nursing home in Peoria after a resident there suffered a fractured hip as a result of a fall from bed.
The resident at issue here suffered from cerebral palsy, cognitive deficits, and paraplegia. This is someone who would have had a great deal of difficulty assisting in her care due to her physical and cognitive challenges. There was a care plan put into place which called for assist of two with bed mobility, keeping the bed in the lowest position, and use of bilateral floor mats. When a care plan is put into place, it falls to the staff charged with caring for the resident to implement it on a day-to-day, shift-to-shift basis.
On the day when this nursing home fall, there was a single aide who was providing incontinence care to the resident. While doing so, the aide had raised the bed and moved one of the floor mats to get better access to the bed. In the process of providing incontinence care to the resident, the aide recognized that she needed a bed pan. She left the room with the bed still in a raised position, the resident unattended, and one of the floor mats moved out of position. When she returned to the room, she found that the resident had fallen from bed.
X-rays were done, which showed that the resident suffered a fractured hip requiring surgical repair.
There were at least three violations of the care plan that took place that resulted in the fall. First, the aide was providing incontinence care to the resident by herself instead of with two people. The care plan called for the assist of two with bed mobility. Bed mobility refers to the ability to change and maintain a position in bed, something that is necessary when a resident is receiving incontinence care. Two people should have been assisting with this rather the one who was actually providing this care. Having one person do a two-person job is a well-recognized formula for disaster (see here, here, here, here, and here for examples). Second, the care plan called for the bed to be in a low position. The bed was in a raised position when the resident fell. Third, it also called for floor mats on both sides of the bed, and the floor mats had been removed so that the aide could get at the resident to provide care, but then the aide left the resident unattended with a floor mats out of position. As a result, we have the resident falling, hitting the floor and suffering a broken hip.
At one level, those violations of the care plan are the cause of this resident’s injuries. However, there is a deeper level to that, and that relates to the understaffing of the nursing home. When the aide was questioned by the state surveyor as to what happened, the aide explained to the surveyor that she just didn’t have time to ask for help in providing this care. When you have a staff that is describing not having time to ask for help, when you have staff that are taking shortcuts in the care that’s being provided to the resident, then that’s a sign of a nursing home which is understaffed, and that’s a nursing home which places residents at increased risk for adverse events, such as falls, bedsores, nursing home choking accidents, medication errors, and so forth.
Unfortunately, understaffing is part of how nursing homes are run. 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: