IDPH has cited and fined Meadowbrook Manor nursing home in Bolingbrook after a resident there suffered a broken leg while being transferred to bed manually by a CNA rather than with a lift as called for by the resident care plan and by the orders from her doctor.
In a nursing home, the Minimum Data Set (MDS) is a tool which assesses the overall function of the resident and the care needs of the resident. One of its uses is that it forms part of the basis by which the nursing home is paid for services so it must be completed under penalties of perjury when it is submitted to the federal government. For this resident, her MDS stated that she was cognitively intact but that she needed extensive assist of two staff with all activities involving transfers, likely due to a history of past strokes. The resident care plan was reflective of this in that it called for assist of two using a mechanical lift for transfers, as did the orders from her physician.
On the night of this nursing home fall, the resident was being transferred to bed by a single aide from an agency, rather than being transferred to bed with a lift being operated by two aides. During the transfer, the resident tripped and the aide fell on top her. The aide got the resident into bed and then reported to the nurse on duty that the resident had lower extremity pain after being transferred to bed using a mechanical lift with the assistance of another aide from that same agency. However, when that second aide was questioned about the incident she denied having transferred any resident with a lift, denied having been asked to help with a transfer by the first aide, and stated that she worked on a different hallway that evening.
Following the incident, the resident remained in bed for three days before being sent to the hospital due to discoloration of her lower leg. There, an x-ray showed an acute comminuted fracture of the proximal tibia (a new fracture of the shin bone closer to the knee with the fracture having many fragments). Her physician told the state surveyor that it was a recent fracture and was the kind of fracture that was caused by an impact and did not just happen spontaneously.
During the hospitalization, the resident experienced a hypotensive event (a drop in blood pressure) which in turn led to increased confusion due to encephalopathy. Her family elected against aggressive treatment and she returned to the nursing home to be placed on hospice.
The obvious cause of this fall was the failure of the aide to follow the care plan and the physician orders to transfer the resident with two staff members using a mechanical lift rather than transferring her manually by himself. A likely deeper cause would be the use of agency staff and the failure to adequately train them and orient them to the care needs of the residents. And while the staffing agency and the nursing home are directly responsible for this fall and injury, the management choices made at the nursing home are a likely culprit as well.
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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