IDPH has cited and fined Alden Courts of Shorewood after a resident suffered a fractured tibia and fibula due to an improper transfer.
The resident at issue had significant cognitive impairments, required extensive to total assist with all activities of daily living, and had functional limitations in range of motion in the bilateral upper an lower extremities. There was an order in place for transfers with the assist of two using a slide board for transfer to/from bed and wheelchair.
A slide board is a device which is essentially used as a bridge that the resident is slid across from one surface to another. It is an appropriate way to transfer residents such as this one who are unable to bear weight with their legs.
On the day in question, the nurse assigned to the resident and an aide attempted to transfer the resident using a pivot transfer technique. A pivot technique is one which is accomplished by using a gait belt to support a portion of the residents weight while the resident stands and pivots from one surface to another. Neither the nurse nor the aide were familiar with the resident. The nurse was aware that there was an order for use of the slide board but she did not see one, so she elected to proceed with the pivot transfer.
As the began the pivot transfer, the resident’s legs were unable to bear her own weight and she was lowered to the ground. They later discovered that the resident suffered a tibia/fibula fracture.
This incident is a textbook example of the consequences that can follow when staff is unfamiliar with a resident and then fail to follow orders or the care plan for the resident. Neither of the people involved in the the attempted transfer here were familiar with the resident and thus unaware that she could not bear weight with her legs. Had they known this, they would have recognized that there was a high risk of a nursing home fall in attempting a pivot transfer. However, that does not excuse the fact that following physician’s orders is not optional. The fact that the slide board was immediately available is not a reason to violate a physician’s orders, and the fact that the nurse attempted to try something else rather than get the equipment needed to comply with the doctor’s orders speaks to a strong likelihood of understaffing.
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